The Sentara Lipid Clinic, featuring Deepak Talreja, MD, FACC, Chelsea Christensen, PA-C, and Jessica Waddell, NP-C, of Sentara Cardiology Specialists, present the newest lipid guidlines, and the newest treatment and dietary strategies
Thank you for joining today's conference. It will be one hour. These are my disclosures. Next slide please, Sam Harris had a proud tradition of being part of a number of groundbreaking trials and that was the majority of my disclosures. We've also worked with a lot of folks in industry to try to make some of the newer medications available to patients and you'll hear about those later. So the thing that really shapes the importance of with ideology in general practice of medicine in this day and age is the fact that cardiovascular disease remains a major player in the US and the world as a whole. If you look at the last 30 years of demographics, we see that among females in green and among males in purple, there's generally been a downward descent in deaths attributed to cardiovascular disease. Now, what's interesting is the lowest period was around 2010. And in the last decade we've actually seen a little bit of an uptick and there are many potential reasons for this. Part of this is the general aging of the population. Part of it is the dietary patterns and exercise patterns of patients in our country. And part of it is ketchup from the tremendous inroads we made for so many years. No one is immortal and eventually you do face some ketchup. But the reason this is important for any clinician to see is more and more metrics are being directed around making sure we're achieving our target LDL and target lipid therapies and the guidelines become ever more aggressive. Next slide please. So if you think about what's going on in the lipid plaque, whether it's the coronary circulation or karate or peripheral circulation, the underlying physiology is truly fascinating. You have deposition of cholesterol in the arterial wall usually prompted by a probie bearing lipoprotein particles. For example, LDL and to some extent V. L. D. L. And I. D. L. And then ultimately when the cholesterol deposits into the vascular space, inflammation ensues macro fish come into that tissue. They absorb the cholesterol and become foam cells and you get an inflammatory response. We often measure that with HS cRP and other inflammatory markers and then you can have destabilization causing acute mes. and even with remarkable therapies we have in 2021, I'll share with you having taking call with a number of my colleagues. On the memorial day weekend. We had 13 stem ease during that weekend of four days. And so the disease process still manifest in the more in the most severe forms of disease. Next slide, please. Now, on top of knowing some of the physiology at a molecular level, it's fascinating. We can figure out so much of what's going on summarizing this slide. What we see is the average American takes in somewhere between 200 and 400 mg of cholesterol a day. That accounts for 25% of the circulating cholesterol in the human body, including both the intestinal and hepatic and then circulatory spaces, 75% of our cholesterol is from entering the paddock recirculation. There are a number of different molecular pathways. For example, there's a receptor called the NPC 1 L1 receptor that's responsible for absorption of cholesterol into the body, deliver absorbs. The cholesterol produces different particles that ultimately become metabolized into LDL and the liver can take these up again. And many of the both dietary and pharmacological strategies are aimed at getting rid of LDL from the circulation so that our LDL receptors take up more of the LDL. We also have HDL that's absorbing cholesterol from the peripheral circulation and ultimately getting rid of it from the body. Although HDL related pathways have been more difficult to encourage. Again, it comes back to diet and exercise patterns and pharmacologic strategies for treating HDL have not been particularly effective. Next slide Right? All right. If you look at this space of lipid ology over the last 30 years, there have been a tremendous number of trials and I hear a little bit of feedback if you don't mind putting yourself on news, if you're not actively speaking that. Great, thank you so much. Um in this space there are a ton of trials with craftily named uh algorithms around them. A lot of these are named for space things or lipid related things. And we see that the green trials are placebo controlled statin trials which are still ongoing. The blue trials are statin versus standard of care. The orange trials are statin dose comparison trials. Then we had a period of the easy to mock trials which are in a deeper orange and then we've gone onto pcs K nine. You can go forward one and then even trials of newer agents, some of which we'll talk about today, very robust trial database has informed aggressively moving guidelines as we go forward and you'll see that in the next slide. So I'm going to start back with the 2018 American College of Cardiology American Heart Association guidelines. These were an iterative step forward in many ways. In some ways they went back to a more basic sort of strategy and what they talked about is focusing on LDL after assessing 10 year risk of atherosclerotic cardiovascular disease. And whereas many of the former guidelines focused on A. L. D. L. Target, these guidelines introduced a percentage reduction as a bigger component Looking in high risk patients at achieving an LDL reduction of 50% or more. I think some people misperceive this as less aggressive than LDL targets. The truth is for many patients that came in with a cardiac event and had an LDL of for example 90. A guideline reduction of 50% aims for an LDL now of less than 45. So in many ways these were very much more aggressive than what we've seen before. But these were really focused on absolutely focusing on what data we could say was absolutely true. And so instead of necessarily just focusing on targets in terms of absolute numbers, they focused on percentage reduction. They looked at expanding the population treated to include high risk patients without vascular disease, patients with diabetes age 40 to 75 looking at low LDS in them and a high risk secondary prevention group getting both the LDL less than 70 and the lipid reduction to a 50% LDL reduction. Now there have been multiple guidelines set since then and we'll look at these next but these form the basis of therapy for a number of years. Next slide here is a more robust algorithmic approach to the A. C C H, a secondary prevention algorithm that sort of focuses those out. I know this is known to many of you and I won't belabor the point, but it was interesting. This is the first guideline set that went beyond just recommending statin therapy added in a set amount and PCSK nine inhibitors based on the data and really talked about looking at that very high risk population and getting to even lower LDL targets. Next slide, the next guidelines set that came out was actually the european Society of cardiology guidelines in 2019. And I'll show an allusion to that shortly. But I think the current most up to date set is the A. A. C. E. A management of display academia and prevention algorithm. From 2020. The American Association of Clinical Endocrinology. Next live this added some different groups. So in addition to the low of moderate high risk and very high risk groups, the addition of an extreme risk group which is patients with progressive progressive atherosclerotic cardiovascular disease and unstable angina uh high risk cardiovascular disease plus diabetes or chronic kidney disease or heterocyclic FH or premature atherosclerotic cardiovascular disease. Now we're looking at LDL targets of less than 55 With a baby targets of less than 70 and triglycerides less than 150 on top of the previous guideline sets that we're looking, at LDL is less than 70 in the very high risk group. So what we see is a progressive Acceleration of LDL targets. Now down to an LDL of less than 55 in this highest extreme risk group. Next slide, next slide, this is what I alluded to with the 2019 european Society of Cardiology guidelines. And europe is often a couple of years more aggressive than us based on trials there. But what you see that's interesting is not only do they look at that extreme risk group with an LDL goal of less than 55 But for patients who continue to have events while taking max tolerated therapy. Now, they're considering our field goals of less than 40. Really impressive reductions based on what we see in indigenous populations, in patients on vegan diet, in places where patients really have the healthiest lifestyles known to mankind, we see those numbers and now the guidelines are suggesting we need to get more and more patients to that group. Next five. So if I'm summarising the ace guidelines, what we see is in that extreme risk group, we're aiming for LDL less than 55. And the guidelines list out what you'll hear from Chelsea shortly, which is of course we focus first on diet and lifestyle maximizing our benefits there and you'll hear more about that in the time to come. And then we think about drugs like statins are the first line in all situations and then the additions of Zeta my PCSK nine inhibitors, cold civil um Mehmedovic acid and even newer therapies coming out. Next slide, I'll just make a quick mention of hyper trackless arrhythmia in the limited time we have today, we ultimately had to focus on the LDL topic since there's so many guidelines around it. But this is gaining increasing uh background and experience and so that this slide talks about some of the things we can do from again, lifestyle changes, treating diabetes, treating thyroid disease, better exercise. Uh careful attention to the types of carbs patients are taking in and omega three and other uh pharmacologic approaches next slide in particular. One new thing I thought it was worth showing in two slides is we have a number of treatment strategies available. But very few trials have shown positive impact on cardiovascular outcomes, which is why this area is murkier. Next slide and I'll briefly mention the recent reduce it trial which looked at E. P. A specific fish oil supplementation. And on the next slide that's you see that that has for the first time in a large scale trial. There are some smaller trial that have looked at this space before that should benefit. But in large scale trials showed a significant reduction in major adverse cardiac events, which was statistically significant. And this will be a topic for future conferences and discussions. Next live at this point I'm gonna turn the floor over to Chelsea is going to talk about LDL lowering. Great. Good morning everyone. My name's Chelsey Christensen. I'm a physician assistant with some terror cardiology. Um I work primarily with Doctor Tell radio to Virginia Beach General and our Virginia Beach office on first Colonial. I'll be discussing alternative statin therapies. I know all of us are very familiar with prescribing statins but many times a maximum dose of statins doesn't get a high risk patient down to their desire to LDL. It's important to know what additional options exist. The main options we'll be talking about our system. I bet epidemic acid and the monoclonal antibodies or injectables such as evolution mob and alla Rocca map, which I'll just refer to as PCS cannot inhibitor fortune next time. This is a great comparison part taking from the american Association of Clinical endocrinology. This looks at common statins against Staten alternatives such as area the PCSK nine inhibitors and bamboo joke acid. Along the top of the chart list, individual agents and class of drugs below each medication, you can see how effective it is at lowering LDL. In that third medication column, we see how superior the PCSK nine inhibitors are at lowering LDL compared to others. This chart also detailed common side effects. If you look at the green versus the red boxes in terms of potential for side effects, you can see Zetia or is it about overall has the lowest risk of side effects with no red boxes. In this column, stands, of course show common side effects of muscle as we've all seen. The main side effect associated PCSK nine inhibitors is Ricky reaction at the site of injection with Mehmedovic acid. We see increased risk of tendon rupture and increased serum uric acid. So it's important to watch for more frequent episodes of gout and these patients, if they have a history of that, I think overall of this chart should show you there are a lot of choices to be aware of when it comes to a patient that either cannot tolerate a statin or is on a max dose of statin but still needs improvement in their LDL. Next slide please. This is a quick diagram in regards to the mechanism of action for lipid lowering agents. Looking at the liver cell in the center and the intestinal villi off. On the right. Numbers one and two show were both epidemic acid and statins work to decrease the synthesis of cholesterol within the past site itself, Number three off to the right. And that small box illustrates how is that a mind works by reducing intestinal absorption of dietary and biliary cholesterol and number four in that bottom right, we see the PCSK nine inhibitor working to block the pCS K nine protein. Each of these strategies ultimately leads to the up regulation of LDL receptors which are expressed by the hepatitis site. Next slide please, we know the efficacy of status C. C. T or the cholesterol treatment. Trialist collaboration is a meta analysis that looked at 14 different randomized child status in over 90,000 patients. To show the below staffs over a five year period with statins, we see a 12% reduction in all courts called all cause mortality, 19% reduction in coronary mortality, 23% reduction in Mrcc death, 17% reduction of stroke and 21% reduction of major vascular events. Next slide, as doctor to discuss the current guidelines have. It's aiming for an LDL at 55 or below for particularly high risk patients. This graph helps to demonstrate the benefit of pushing that LDL lower yellow curve represents primary prevention and that white curve represents secondary prevention. You can see the Y axis of this graph is event rate in percentage versus LDL achieved along the bottom or the excess overall. This graph is shown that the lower we can get the LDL, the lower the rate of cardiac event occurrence. Next slide, okay, piles of stand versus placebo. There's a lot happening on this slide. We've been pushing down therapy for decades but we still see that major CBD events can still occur despite statin treatment with major studies along the bottom, we see that significant still isn't that great when it comes to placebo vs. Gotten used. Essentially. The point here is that the statin group does better when compared to placebo, but there's still room for improvement where alternative LDL lowering alternative therapies can play a role. Next pipe. Next slide, please thank you. Uh managing stand intolerance with statins coming most common complaint. We hear from patients which is muscle cramps, muscle weakness, etcetera. I think it's important to note that um I myself and others I know frequently see patients who have been unable to tolerate one stat and due to cramping, which is documented their chart. But if you take a second to ask that patient, have you tried another statin before many times, The answer is no. And the patient had the understand that failing one means they'll fail them all, which is not necessarily true. Simvastatin the one most likely to cause muscle aches. Whereas Lewistown and atorvastatin has the lowest occurrence of muscle side effects. It's absolutely reasonable to try a different stand if a patient has been unable to tolerate a certain one. Previously, we see the incidents of statin associated muscle symptoms be roughly 5 to 20% no more severe reaction with rhabdomyolysis being about one in 10,000 when Mosul symptoms occur. If they are severe, you can discontinue starting to consider re challenging with it once symptoms have resolved, you re challenge in a lower dose thing like a few times a week or every other day. As the patient can tolerate, recommend trialling at least two stands, especially if you're moving towards using a PCSK nine inhibitor. Usually you need to have documented failure of at least two stands before. Insurance companies will consider covering that PCS canine injectable option for the patient. Next slide please. The improvement study in 2014, which we participated and looked at patients that were less than 10 days out from a significant A CS event. And then we started on either simvastatin 40 mg daily or simvastatin 40 mg daily. In addition to Zetia 10 mg daily Study followed these patients at 30 day follow up every four months for about 2.5 years total. Next slide please. The primary endpoint here was improve it was that the group that was maintained on combination therapy of statin plus said Ahmad had a reduced risk of cardiovascular events when compared to the group on statin therapy alone. The blue line here, of course the solitary simvastatin used the event rate over time versus that yellow line is simvastatin the wished that you used next slide. Okay, PCSK nine inhibitors or trainings were pasta and prevalent are starting to become quite popular. We're seeing more commercials for them on tv. More patients are enquiring about it at their appointment, which is great for those that aren't familiar comes packaged as a one time injectable use pen has to be stored in a refrigerator depending on which brand you're getting. The injection is self administered at, held by the patient once every two weeks or months, depending on what the provider prescribes describe. It helps to show how the PCSK nine inhibitors actually working off towards the left. You can see the PCS canine attaching to the LDL receptor. Normally, the LDL particle binds to the LDL receptor and is brought into the hepatic site. The receptor essentially been dropped off the LDL returns to the surface to pick up another LDL particle with the PCSK nine inhibitor. Once that receptor dropped, drops office LDL receptors then destroyed, therefore unable to return to the surface and cannot continue collecting LDL. Next slide please. The furrier cardiovascular outcomes tribal in town 2000 and 17 helped us look closer at statin and placebo versus Staten and ripa to this slide demonstrates a dramatic difference in LDL lowering between the two bottom red line shows us a combination of staten Epatha together was a substantial decrease in LDL roughly a 60% reduction over weeks when compared to statin and placebo. You should also notice just how quickly that 60% reduction LDL can occur with time and weeks. Along the bottom. We can see that LDL reduction in as little as 4-12 weeks. Next five please. This chart again similarly shows a significant difference in LDL reduction between StateN of placebo versus standard Epatha. We saw a 20% reduction in cumulative incidence of TB death, M. I. And stroke when these patients were followed over a several year period. Next slide I've mentioned epidemic acid several times. This graphic helps demonstrate the mechanism of action for this drug. If you're not familiar with it, it comes in two formulations epidemic acid by itself, which is marketed as an ex little and then there's a combination form, which is a joke acid plus his enemies. That combination form is marketed as next Lizette. What's important to note here that Murdoch acid does not have the muscular side effects that we see in statins. It is not convert within skeletal muscle into an active form, the way that statins do. So, Ben, murdock acid is only active in the liver, not in muscle and liver like statins. I think we're starting to see more and more use of epidemic acid. I know we're seeing more. You stay in our office. It's been a good alternative to have when you encounter cost issues with the PCSK nine inhibitor, which unfortunately you likely will. I think patients are always hopeful to hear there's something else they can try as an alternative. Next slide please. The slide looks at phase three clinical trials for next visit, which was the best Madoka acid and a set of my combo. It specifically looked at high risk cardiovascular disease patients who are already on maximum tolerated statin dose For the trial patients were randomized to either taking next Levett next to tall is enemy only or placebo for a 12 week period. Next slide please. At that 12 week mark. You can see there was a significant drop in LDL next therapy Roughly 38% decrease of LDL well compared to an extra tall. Or is it to me when they reach used independently. This helps us illustrate that if you're considering starting Mehmedovic acid in a patient that data is shown to use the next option or that combination of epidemic acid and is enemy to maximize your chance at LDL reduction just for a quick verbal summary. When everything I talked about what I'd like you to take away, that if you're encountering a patient who has either trial multiple statins have been unable to tolerate them or they're on maximum dose statin and still need improvement in their LDL. I'd like you to consider the options of bandido Cassidy. Said, um, I've and the PCSK nine inhibitors using an additional therapy like these will help get your patients, they'll be all closer to goal and ultimately help decrease the risk of cardiovascular disease occurrence or even recurrent. And we'll go to the next slide and I'm going to let Jessica Weddell takeover for more diet, lifestyle management things. Yes. Thank you very much. Um, can you all hear me? Yes. That's great. So yeah. Good morning everyone. And thank you doctor tell regimes for allowing me the opportunity to work with you and Chelsea to put together this morning's presentation to be part of our new lipid clinic within centering cardiology specialists. Since time is limited. We'll get started with what I think is one of the most important in my absolute favorite topic to discuss within lipid management and actually just cardiovascular management in general lifestyle modification for lipid management can really be applied to any disease manifestation that we currently deal with that can directly impact are circulating lipids. This includes metabolic syndrome, diabetes, obesity, along with other conditions that can coexist with this lymphedema, including hypertension of the meeting tobacco and alcohol abuse. Next line. So the objectives for today as follows to review dietary recommendations for living management, review some exercise guidelines to help aid olympic management and review overall impact of lifestyle modification changes on the overall olympic management. Next line. So of course, when we talk about lifestyle modification, the first big topic is diet. Diet is always a hot topic, whether we're even talking about lipid management in general. And it's usually the first question I get when I see a patient coming out of the hospital after having an acute M. I. A new diagnosis of heart failure and even atrial fibrillation. And the question always is So what can I eat? My goal is is certainly not inundate everyone by going through each specific diet, but to introduce a few new concepts every recently came across from attending the National lipid Association conference a few weeks ago. Next line, the guidelines put forth by multiple organizations, including ones previously mentioned by DR Tell Abrasion and Chelsea, but that also include the H A. C. C in L A S E A S E A S A D. A. Endocrinology societies as well as dietary societies. All agree that certain lifestyle changes in particular would diet is a critical essence when treating display academia. And I also have to think having that dietary discussion can be a very daunting and difficult and challenge given the limited time that most clinicians are allotted. So this is just a little side point. But I think that's why I highly stress the utilization of other team members including our registered dietitians um or are for prior for exercise recommendations reaching out to our exercise physiologist, personal trainers within the community or other exercise programs such as the Y. M. C. A. And other health fitness organizations. Dr pentagram, he's Wellness Clinic and Dean Ornish or to other programs that were recently mentioned that are offered within Sentara who can help with behavior modification and further enforce and educate on making appropriate lifestyle changes particularly with diet. Even our pharmacists I feel um are sometimes under utilized as part of that team. Um They can help us not only better understand these newer agents and the motive, you know the mechanism of action of which how they work but also in understanding how some of these medications can even interact with particular foods that we may be recommending. So the team within healthcare is critically important to the success of our patients and also for us as clinician and to remember that we're not alone when it comes to helping with reinforcing these recommendations and then I'm about to review with you. There's a lot of information and there's a lot of great tools within Sentara that we can be utilized um And also again as dr toleration mentioned at the beginning that hopefully our lipid clinic and having us out there as people you can reach out to um that we can be abused to you as well. So the verdict is in every major society has put forth guidelines for lipid management. All stressed the idea that lifestyle modification is key and the number one recommendation when it comes to lipid management, dietary modifications include the following, reducing saturated fat intake is increasing fiber intake through fresh fruits, vegetables, legumes, beans, whole grains, reducing intake of processed meats and increased plant protein and or plants in general increasing movement or through exercise smoking cessation as well, stress management which are not on the slide but also want to mention too that the elimination of processed sugar which we know leads to diabetes hyper trickle trickle is writing me which are both strong A CVD risk factors next slide. So this is an example of um one of the particular guidelines that came from the A. C C h A 18 4019 guidelines for a STD risk management reduction. And although these recommendations are for overall a STD risk reduction, these recommendations are the same essentially when we talk specifically about lifestyle modification for Hyperloop anemia, remembering that LDL C. Is actual causal factor for the development of a DVD. Um So as previously mentioned, multiple societies approached this lymphedema dietary management the same. The dietary concepts remain the same with regards to reducing more or less saturated fat intake and replacing with mono or polyunsaturated fats, limit trans fats, increasing whole grains, vegetables, fresh fruit limiting animal protein intake and introducing more plant based proteins such as lagoons, tofu. Um and reduce refined processed meats and sugars. These recommendations are are recommended for all persons of all ages and all genders. There is no bias here at all slide. And so this brings me to my next question that usually comes up when within practices. Um so what's the best way to get out there? And you know, I listed some of the most common diets and names that are essentially thrown out there in in, you know, mainstream media, but um I think that we kind of all know that the answer to this next line is that not, there's really no particular diet that is the healthiest and I say diet because that can be a term that's loosely thrown out there and it can come with a lot of negative and emotional feelings as we talk about making lifestyle changes to improve our overall health and in our lipids. Um, diets again, when we're talking, quote unquote diets, they are not necessarily lifestyle. And unless you can find a particular diet that will fit into your healthy lifestyle, such as the mediterranean plant based vegan or even some low carb options for some people. Um, you really are going to have a hard time getting patients to really adhere to some of these lifestyle changes. Um, and then again, of course, unless your patients can go directly and qualify for something like the Dean Ornish program, again, the key really is lifestyle modification, long term success, long term outcomes that we want for people to stick for for for many years to come. So we, whenever I think about this and talk about this, I think about the infamous story of the you know the hair versus the tortoise, you know, the slow and steady wins the race, not these, you know, which Um you know, two week programs that are guaranteed to make you lose £20 because guaranteed that's going to come back and patients fall right back into their old dietary patterns next line. So as I mentioned a few weeks ago I attended the National lipid Association. So our scientific sessions, uh they're registered dietitians. There's a lot of great information out there online to from the N. L. A. Um to get more information regarding dietary patterns and changes that are recommended. Um But one term that I thought that was really interesting that I think they're gonna start kind of including some of their guidelines as the concept of plant forward eating. And basically the concept is to promote more integration of vegetables and plant based products into one's current everyday dietary pattern or to teach one to replace the small increments plant based proteins or including more vegetables intermittently throughout the day, week, month, wherever that particular patient is at in, you know trying to make those changes, anything, anything is better than nothing. And again, you know, think slow steady wins the race, not necessarily making big drastic changes all at once. Um And there's certainly uh there's another concept on there to the flexitarian um which I probably would would constitute myself as being in. Um It consumes more sources of protein from poultry fiscal but also sticking them mostly with a underlying plant based um nutrition as well. So so again another term if you want to if people want to use that. Um But long term progress really important. Another thing worth mentioning from the slide is um that there is there are multiple studies out there that do demonstrate the overall benefit from including more plant based proteins within one's diet. One particular study that they had mentioned was from the Journal of American Heart Association that demonstrated an overall mortality benefit from increased plant based proteins intake Just replacing 3% of energy from various animal protein sources with plant protein was actually associated with a 10% decrease in overall mortality for both men and women. So again, key think long term um you know whether people want to put a label or not into um you know how they're choosing to consume them their their diet. Um You know, these are just basic reference guidelines of you know, recommendations to help them make better healthy changes for the long haul next time. So moving on from diet next, we'll discuss the importance of exercise and actually we have we are blessed to have on another one of our colleagues who is a physician assistant within a group. She's new, she has a background with an exercise physiology and I asked her to shut she had any good resources or anything to really add in regards to exercise and lipid and and its direct roles on lipid management. And basically what she said to me, which kind of what I gathered from my own reading and understanding was to conclude that that really it's the combination of diet and exercise helps with weight loss, which then can have a dramatic impact on liberty reduction with or without the use of these medications. Um And I have actually a personal experience, my a family member of mine healthy 38 year old male. Very physically active. Um I mean he's been exercising his entire life. I've known him for that, um very active with his job. He actually has cholesterol numbers done back in 2000 and 19 and his total cholesterol was 234 and his LDL was 1 75. So you and I us here in the lipid world and cardiology would be kind of thinking like, whoa, you know, that's that's a pretty high LDL and he's kind of borderline, you know, suggesting and thinking that maybe he's got some underlying um you know, familial component to it. But so recently he went on a diet, we'll call it quote unquote diet because he actually, you know, after three weeks that he did and he fell off the bandwagon. But um because after three weeks of following what's called the Daniel Fast, which is actually a biblical, it's it's a very strict vegetarian diet approach and it's it's it's again, it's in the bible. So if you want to research and look into it, um if you're into that, it's Very interesting. But essentially it's it's a strict vegetarian diet and he went on it for about three weeks and he had his blood cholesterol checked even after just three weeks, and his total cholesterol dropped 143 And his LDL went down from 1 75 to 92. So that just again kind of shows and prove to me the impact that really diet ultimately has on our overall lipids. Um and even with weight loss strategies, um there is that old adage that it's 80% diet, 20% exercise. And it actually is true, but really there's a lot of benefits of exercise that are necessary for that indirect impact that can have on weight and reducing the risk of, especially like metabolic syndrome and in our lipids. So what does exercise important? Excellent please. Um So it's important obviously for weight loss reduction of developing cardiovascular disease, better control with diabetes and metabolic syndrome enhances overall wellbeing, stress management, boost energy, improves blood pressure, keeps joints mobile and improve sleep next next line. Um And so yes there is a difference between being physically active and exercising. So physical activity. Of course we think about what we're doing throughout our day. You know how sedentary is somebody being. Um And then is with with exercise. Of course we know that's defined as a scheduled specific period of movement carried out for a specific duration of time and the best is to be doing both. And again I'll bring up the adage of you can't out exercise a bad diet and you cannot exercise a sedentary lifestyle. Um I didn't include it in this presentation just for time but there's there are studies that have been done looking at that. Uh And really we've got to get people just being more physically active during the day. And again these recommendations to our for they are the same our next like please. So these basic recommendations for overall exercise pattern um by the A. J. The american College of Sports Medicine, american diabetes association. All all the people who look at exercises you know strong component for lifestyle put out the same C. D. C. Um At least 100 and 50 minutes of moderate intensity or 75 minutes of vigorous intensity activity spread throughout the week. We're looking at probably 300 plus minutes or more needed to help with the aid of weight loss Um strength training but at least two times per week working on more major muscle groups and keeping in mind again, overall physical activity. And I want to stress the importance that these are the same exercise guidelines for patients at 65 and older, which is a very big population that we deal with, especially in the world of cardiology. Um people are shocked when I tell them this again, it there's no bias, it's a gender age. There may be some bias here when we're talking about certain physical disabilities, but again, there's a lot of different exercise modalities out there. We just got to get patients kind of, you know, thinking about that and more motivated to kind of look for those resources. And also, you know, clinicians us taking the time to kind of look for those resources to for them because they really do come to us um asking and that's probably the third most common question is that I do receive is so what type of exercise can I do? How much exercise should I be doing? And you know again these are just some basic guidelines but I would really looking to um reaching out to to our resources here. Um That we do have not only within Sentara but also in the community as well next line. And there's certainly multiple studies that have demonstrated that the proven power and benefit of exercise not only in primary prevention of A. S. D. V. D. But also secondary prevention. This was a study done looking at all the all cause mortality in patients with coronary artery disease. And basically what this suggests is the higher the metabolic equivalents or the exercise done throughout once a week. Which they broke it down as to metabolic equivalents or hours per week. Um The greater reduction it showed an overall mortality benefit. And so I I also again stressed to our patients, it's it's never too late to learn to exercise. You may not love it, but we got to promote it. Um and it's certainly not wasted time spent with exercising despite if somebody continues to have ongoing, you know, issues. Obviously we know that the healthier somebody is going into having some sort of event on the flip side, they're going to be that much more healthier. And so so exercise is beneficial in all shape or form. Next line. All right, so moving on from, oh and one more thing, actually, I do want to point out from the American College of Sports Medicine as I was talking about reaching out to resources um that I didn't get a chance to include on here because I found it last night. But the american College of Sports Medicine has an initiative out there. It's called exercise is Medicine. Um They actually came out with a tool that was designed for providers to be able to to prescribe actual exercise to their patients. It's a new novel tool specifically for patients with multiple cardiovascular disease risk factors. There's an algorithm that was that was put forward for it. Um That kind of helps you take you through through, you know, like if a patient where they a prior exercise or Yes, no. Um you know what type of risk factors do they have and it kind of takes you down that that pathway to help them kind of engage in figuring out what type of exercise if you're as again, I'm sorry, I didn't get a chance to include X. I just came across it last night in my email, but if you get, if you are really interested send me an email, I'll be happy to share that information with you. But again, it's through the american College of Sports Medicine and its exercise is medicine and has a lot of great tools to for us to help really initiate and actually prescribe exercise to patients. All right, so moving on. Tobacco and cardiovascular disease, um this is of course another important lifestyle modification for living management. Um Tobacco increases the cardiovascular risk multiple pathways as you can see here, that's illustrated on the slide, but the one that I think that is really most important and what dr toleration was teaching us from earlier about LDL. Um And that pathway of how cholesterol becomes, you know, and it becomes a pathological status is that oxidation process that takes step and oxidation whenever that that's inflammation, oxidation, inflammation. And so the same also goes with the HDL process that he even talked about two. But what's interesting is is um the you know tobacco component enhances the oxidation process um on our cholesterol not only with LDL but also HDL. And there's some suggestion that if we do get patients to quit smoking we actually see an improvement. We can see an improvement in their LDL but also there HDL utilization and in some some places have even suggested that HDL may even go up. So I I think that's the tobacco is really important that we stress of course ongoing and then we all know that um Alright next slide and last slide and this is Justin summering. So multiple lifestyle changes can directly impact liquid management. The key takeaway from today regarding lifestyle changes um include the following um cardio protective diet including fresh fruits, vegetables, whole grains, legumes, not seed, um war non tropical fats, oils. That's with the consumption of less saturated fat, more consumption of mono and polyunsaturated fats, um consuming more healthy types of fish, seafood, lean plants and animal protein if that's what one desires. Um and low fat dairy foods and again, stressing the decreasing saturated fat trans fats in the diet, decreasing overall cholesterol intake, um processed meats and highly refined sugar, carbohydrates. And again, if we want to put a label, the mediterranean vegetarian diet dash flexitarian or even the plant forward dietary approach are all great ways to get patients engaged and kind of give them down that path of maybe giving them a term to start doing some research on and better understanding for themselves. Um We want to encourage them to participate in regular routine exercise and maintain adequate physical activity during the day, smoking cessation. Of course, stress management reduction, which we didn't really talk about much, but you know, stress, We're never going to get rid of stress that's just given stresses everywhere. But would I encourage patients to think about is how they're coping with that stress. And so with that I turn it back over if there's any questions and and again I think everybody for their time and um thank you, Doctor Tell raja and administration, thank you so much.