RISK FACTORS

The risk factors connected with CHD are classified to: a)Modifiable: these include smoking, hypertension, hyperlipidaemia (increased lipids, such as cholesterol and triglycerides, in blood), diabetes mellitus, diet (rich with saturated fats and carbohydrates), obesity, heart failure and left ventricular dysfunction, specific behavior (being competitive or combative or feeling overly stressful) and sedentary life style (lack of physical activity).

Other modifiable risk factors, but with less proven data to support, are depression, increased blood fibrinogen (which is a factor of blood clotting), increased blood homocystein (congenital with premature atheromatosis or from decreased intake of vitamin B12 and folic acid) and decreased intake of Vitamin B6 .

b)Non – modifiable: increased age, men (if less than 65 years old, because of the protective role of estrogens on women), race (e.g. from India), low socio – economic status, personal or family medical history of CHD, and finally low birth weight (IUGR, SGA).

We can target to the modifiable risk factors by stop smoking (and avoiding passive smoking) and also by controlling diabetes mellitus (DM) and hypertension with medication, exercise and diet (avoiding sugar and salt). We can also reduce the risk for CHD by controlling obesity (with diet, exercise, surgery –if morbid and medication), by treating heart failure and by taking adequate folic acid and vitamins B12 and B6 (e.g. from diet or taking a multivitamin pill).

OBESITY

Obesity is a major problem. Measuring BMI helps classification of obesity. BMI is estimated by: weight (Kg)/ [height (m)]2 . BMI 18,5 – 24,9 is normal. BMI 25 – 29,9 is overweight. BMI 30- 39,9 is considered obesity and BMI equal or more than 40 is morbid obesity. Obese people aren’t aware that have decreased life expectance than non obese. Namely, they die earlier. Obesity starts from childhood. The main stem of treating obesity is diet and exercise.

Obese should follow a low calorie diet (there are specific calorie books and also all products mention the calories) with a target of losing 0.5 – 1 kg (1 – 2 lb) weekly and this is achievable with using diets of 1500 kcalories daily. A dietician can offer a specific diet. Diet shouldn’t only be with low calorie intake, but also poor on fat and refined carbohydrates and rich in fibers, pulses (legumes), fruits and vegetables (fibers also protect from colon and other cancers).

Regular aerobic exercise also helps losing weight. For morbid obesity there are specific drugs such as orlistat (it decreases the absorption of fat that we take with foods) and sibutramine (but it has the side effect of increasing blood pressure and heart rate). Surgery is the last solution for morbid obesity. Also obesity is connected with psychological problems, such as depression and stress, and there are special psychotherapy techniques or counseling for obese.

Obesity increases the risk for many medical diseases such as CHD, hyperlipidaemia, hypertension, CVA (stroke), DM (diabetes mellitus) type 2, gallbladder stones, psychological problems, post surgical complications, sleep apnea, pulmonary problems, increased mortality risk ( for BMI >30), cancer (breast, colon, cervix, uterus, ovary), back pain and arthritis (knees, hips), menstrual problems (irregular menses and ovulatory failure), PCOs (polycystic ovaries), stress incontinence and also complications in pregnancy (gestational DM, hypertension and pre – eclempsia and difficult delivery). Waist circumference equal or more than 94 cm (37 inches) for men and 80 cm (32 inches) for women increases the risk for CHD and DM.

CHECK UP

We all need to take annually a medical checkup, including a blood test for cholesterol (total cholesterol which should be less than 200 mg/dl or less than 6 mmol/L, good cholesterol HDL should be less than 100, and bad cholesterol LDL should be more than 60, triglycerides should be less than 160 mg/dL or less than 1,9 mmol/L), clotting tests (including fibrinogen), blood homocysteine and blood glucose. There is recently a specific CRP fraction that shows increased risk for MI. Blood tests should also include Lipoprotein –a .

The checkup on patients more than 40 years old should include an electrocardiogram (ECG), and a standard exercise test (such as treadmill). There also many other preventive tests described on another text I have written about ‘preventive medicine’ and you can find on this site.

PREVENTION

We need to check often our blood pressure (its high if it is equal or more than 140/90 or 135/85 in diabetics without macrovascular disease or 130/80 with it), and by measuring our weight and aim to decrease our weight if our BMI (weight/ height2 ) is more than 25.

About the CHD prone behavior, we need to by avoid being combative, aggressive and competitive. Anger control schools, counseling or psychotherapy (by a psychiatrist or psychologist) and relaxing techniques help. There are many relaxing techniques such as yoga, exercising, massage/ shiatsu, hobbies/sports (e.g. swimming, jogging, cycling), biofeed back, aromatherapy, relaxing music etc.

There are also some drugs that help the prevention of CHD and stroke such as classically aspirin 75 – 300 mg od (once daily) and maintenance dose 150 – 300 mg for acute MI or stroke. Avoid taking it concomitantly with other anticoagulants (such as warfarin) and prefer an enteric coated preparation. You also have to take drugs that decrease the acid of the stomach (such as PPIs e.g. ranitidine, or H2R antagonists such as pentoprazole) because aspirin may induce peptic (gastric) ulcers.

Aspirin has many contraindications (especially bleeding diseases and surgery) and also many side effects (such as gastric ulcer, asthma exacerbation, renal problems in overdose etc), and clopidogrel is (75 mg od) is an alternative if aspirin cannot be tolerated. However, you should always take aspirin, and any other medication or herb only under your GP’s guidance.

Other preventive drugs are the statins used for hyperlipidaemia (increased cholesterol or triglycerides), that have also side effects such as increasing the liver enzymes and myopathy. Evidence shows that ALL patients with CHD benefit from the reduction of their blood cholesterol and LDL by using statins, regardless their initial cholesterol concentration!

Prefer red wine (maximum 3 SMALL glasses daily on men and 2 on women) that has many antioxidants such as phenols etc. There are also many other antioxidant foods, such as Vitamins A, vitamin C (in oranges and also in wild roses), vitamin E, black chocolate, olive oil (vitamin E), green tea, herbs (such as Ginkgo Biloba that prevents dementia), garlic, beetroots, cauliflower etc. Antioxidants help us preventing vascular diseases, cancer and even dementia, all connected with the oxidative stress from free radicals (especially of Oxygen) that ‘attack’ to cells and their nucleus (DNA).

Another substance that helps prevention of CHD are the ω6 and ω3’ fat acids which decrease triglycerides and are contained in fish oil in fat fish such as mackerel and also in vegetables and nuts (however we don’t need to eat too much nuts and avoid the salted ones especially cassius). People eating much fish are Japanese. Traditionally, CHD rates are low in Japan, something that isn’t noted on Japanese immigrants in the US that follow the traditional American junk food! However, for unknown reasons Japan has a higher rate of gastric (stomach) cancer.

Nitrosamines are conservatives added to meet (especially salted meat, sausages and canned meat) and are a culprit for gastric cancer. Also smoking and infection from helicobacter pylori may also cause gastro – esophageal cancer. Aflatoxin (found on nuts), estrogens, alcohol and infection from hepatitis B or C may cause liver cancer. Estrogens, found in COC pill (contraceptives) and estrogen replacing therapy after menopause, are connected with breast and endometrial cancer, liver cancer and also with high risk for DVD (Deep Vein thrombosis) and pulmonary embolism. Women should be aware about their side effects and contraindication (e.g. patients with migraine or clotting disorders).

HEALTHY DIET

On diet there are also substances that prevent CHD such as alcohol in low doses (especially red wine), plant sterols and stanol esters and β’ glycanes (that can be found added in specific dairy products and toast breads which are advertised that lower cholesterol), soya protein and walnuts (that also decrease cholesterol), fibers (fruits, vegetables and all bran cereals) etc.

We also need to avoid trans saturated lipids (that help the obstruction of our vessels), salt and sugar, that unfortunately are all contained in most products, from snacks, deep fried, chips and hamburgers, even in products for infants. Unfortunately atheromatosis and CHD is created from junk food that most eat since their early childhood!

A healthy diet includes 5 portions of fruits and vegetables daily. Also includes a diet rich in legumes (pulses). We should avoid fat, and carbohydrate intake (especially processed and red meat, full fat dairy products, butter spreads, snacks, crisps, sweets, salted peanuts, canned and prepared food high also in salt and sugar) and hidden sugar (alcohol, prepared food, snacks).We should replace refined carbohydrates (sugar) with unrefined carbohydrates and starch (all bran black bread, rice, non fried potatoes) as energy source. We should avoid excess salt especially hidden (snacks, crisps, prepared and canned food etc).

The main stem of a perfect diet is plenty of fruits and vegetables and also fat fishes (mackerel, herring, salmon, pilchards), and also plenty of fibers (all bran cereals, pulses, beans, whole meal black bread, oats). We can substitute meat with vegetable protein such as pulses and soya. However we should not cut red meat because it offers (meat’s iron is better absorbable) and B12, which deficiency may cause anemia, neurological and psychiatric disorders and may induce coronary disease or heart attack by increasing .

Vegetarians and vegans aren’t aware for the risk of iron and B12 deficiency. They should take them at least with a pill (multivitamin pills should be taken with food, but iron needs to be taken with empty stomach). Human kind wasn’t born vegetarian. We aren’t sheep! Initially cave people ate only meat. I personally recommend people to eat meat one or 2 times weekly and prefer skinned chicken and turkey (but eat at least 1 day weekly read meat). When we eat meat we have to remove the excess fat and poultry skin. Also steaming (with a steaming cooker) foods is better than other cooking methods. Frying is the worst.

When cooking with fat we should better use olive oil and not butter or other saturated oils (the worst oil is palm oil, used often in fast foods). We also better use skimmed dairy products (milk, yogurt etc), avoid spreads and yellow or hard white cheese (I think the best cheese is low fat cottage cheese) and avoid biscuits and deserts. We should drink at least 4 – 6 pints (2 – 3 lt) of water/fluid daily, but avoid tea and coffee (both are stimulants) and alcohol. Regular water intake ensures the good function of our kidneys.

However, we should eat plenty of fruits and vegetables, increase water intake and salt in case of very hot days of summer, because many people (such as a few years ago in Paris) have died, especially elderly, because of heat exhaustion that induced dehydration (which increases clotting and risk for MI and CVA) and electrolyte imbalance that may cause serious heart arrhythmias. Furthermore, people with medical problems should consult their physician for modifying their medication dose during very hot days.

Also we should be aware that a drug may cost our life in case we stop it abruptly (such as β’ blockers and other antiarrythmic drugs), or take a wrong dose or take them concomitantly with other drugs. For example diuretic drugs (e.g. for heart problems such as heart failure CHF) can increase or decrease potassium or magnesium levels causing lethal cardiac dysrrythmias.

DIABETES & METABOLIC SYNDROME

Diabetes Mellitus (DM) is a major reason of premature atheromatosis (fat deposits on the inner wall of the vessels) that later causes CHD, MI and CVA (stroke), renal failure (microalbuminuria in diabetics is a premature indication for renal disease), retinal disease (retinopathy) and blinding, neuropathy (mononeuropathy or polyneuropathy and also autonomic neuropathy and neurogenic bladder) and ulcers/ gangrene on feet. All these are connected with micro and macrovascular disease.

Patents with DM are prone on serious infections such as UTIs (Urinary tract Infections), mucormycosis (nose & sinuses infection), ear infection from Candida, necrotizing fasciitis, sepsis and coma from diabetic ketoacidosis (DKA) on type 1 DM, or hyperosmolar coma on type 2 DM.

The diagnosis of DM is accomplished by measuring venous plasma glucose. We have DM when a random glucose is equal or more than 11, 1mmol/lt or if fasting glucose is equal or more than 7 mmol/L or 115 mg/dL. DM is classified to insulin dependent type 1 IDDM or juvenile (treated with insulin) and type 2, none insulin depended (NIDDM), maturity onset (treated with hypoglycemic drugs and sometimes also with insulin).

Metabolic syndrome is a very common syndrome that increases the risk of CHD and CVA (stroke) and other vascular diseases. It consists of impaired glucose tolerance or DM, insulin resistance, trunkal obesity (waist circumference more than 1 m on men and more than 0,9 m on women), blood pressure more than 135/80, dyslipidaemia (high LDL, low HDL, and high triglycerides), increased uric acid etc.

Glycosylated Hemoglobin (HbA1c) is a helpful biochemistry measurement of blood sugar control over the previous 6 – 8 weeks and should be measured at least every 2 – 6 months. Normal HbA1c is 4 – 6%. Target HbA1c is less than 7,7, or less than 6,5 if increased risk of vascular disease. Patients with DM should control frequently their blood sugar (with blood stick device). They should also aim to lower their cholesterol and LDL (with diet and statins). Their target BMI should be 25. Their target BP should be less than 135/85 or in case of macrovascular disease less than 130/80 (with diet, avoiding salt and using antihypertensives).

Diabetics should have a special healthy diet (better written from a dietician), exercise regularly, stop smoking, wear alert bracelet, have influenza and pneumococcal vaccine, have foot care at podiatrist / foot doctor, notify the DVLA (driving license service) if DM is brittle, and also have a kit with prepared glucagon injection for hypoglycemia.

HYPERTENSION

Hypertension is another great medical problem. It is defined as blood pressure (BP) equal or more than 140 (systolic)/90(diastolic). 95% of the cases have unknown cause and then it is called ‘essential hypertension’, but alcohol and obesity may contribute. Other causes for the reminding 5% are renal disease (e.g. renal artery stenosis or glomerulonephritis GN or nephritic syndrome), Cushing syndrome (e.g. from steroids) and disease, Conn syndrome, acromegaly, pheochromocytoma, hyperparathyroidism, hyperthyroidism, pregnancy, (gestational hypertension or eclampsia) and coarctation of aorta.

Hypertension is relied with many complications such as CHD and CVA (stroke), MI (Myocardial Infraction), CHF (congestive heart failure), ARF (acute renal failure), retinal disease of the eye and blinding. Malignant hypertension (diastolic pressure more than 140 mmHg) may be fatal and cause pulmonary edema, stroke, MI, ARF, hypertensive encephalopathy and aortic dissection. Treatment of hypertension includes life modification with diet (avoid fat and salt), exercise and antihypertensive drugs. Target BP is less than 140/85 on non diabetics, and less than 130/80 on diabetics and patients with chronic renal disease and cardiovascular disease. Relaxation techniques also help.

Patients with hypertension should stop smoking, lose weight if overweight or obese, regularly exercise, and decrease alcohol, caffeine and salt intake and increase fruit and vegetable intake. If indicated, satins and aspirin are used to prevent the risk of cardiovascular and cerebrovascular disease and prevent MI and stroke. As all patients, especially those taking drugs for heart problems, or antibiotics or psychiatric drugs, they should never stop abruptly their medication in any case.

INCREASED CHOLESTEROL & LIPIDS

Hyperlipidaemia may be familiar, so people with family history of CHD or hyperlipidaemia and/or relatives who died young (< 50) from MI should check with blood tests if they have familiar hyperlipidaemia. We also must be aware that many drugs induce hyperlipidaemia and such drugs include steroids, β blockers (!), thiazide (a diuretic), COC (for contraception, ‘the Pill’), and isotretinoine (for skin problems such as acme).

Also many diseases increase blood lipids (fat), including DM, hypothyreodism, renal failure, nephritic syndrome, Cushing syndrome, myeloma, porphyrias, cholestasis, PCOs (polycystic ovaries syndrome), glucogen storage disease and lipodystrophies. Also pregnancy and excess alcohol increase lipids. Pregnancy increases also the risk for DVT (Deep Vein Thrombosis) and Pulmonary Embolism and high risk patients should take anticoagulation therapy and also avoid prolonged trips with car or airplanes.

Patients with hyperlipidaemia are treated usually with statine. However they need a special diet (consult a dietician) with decreased intake of saturated fats and cholesterol/ triglycerides (butter, snacks, red meat, full fat dairy products) and decreased sugar intake (sweets, refreshments, snacks, drinks with alcohol). In case they have BMI more than 25, they need to lose weight. They should also stop smoking, start regular exercise, avoid excess alcohol and prefer products (usually dairy) enriched with plant sterols and stanol esters.

ALCOHOL EXCESS

About alcohol, excess consumption has the opposite effect and increases the risk of hypertension and CHD. Alcohol is also relied with many other problems such as fatty liver, hepatitis, liver insufficiency with cirrhosis (including portal hypertension with high risk of fatal bleeding from esophageal varices), peptic ulcers, Wernick Korsakoff psychosis (lack of vitamin thiamine), polyneuropathy, breast cancer, alcohol dependence and alcohol withdrawal syndrome (with the high mortality ‘delirium tremens’).

Furthermore, high alcohol intake is connected with sexual dysfunction and infertility, CVAs (stroke), myopathy, cardiomyopathy, gastritis, pancreatitis (acute and chronic), DM, obesity, cancer (mouth, larynx, esophagus, breast), nutritional deficiencies and malnutrition (thiamine, magnesium and other electrolytes etc), sleep disturbances, psychosis, injuries (car accidents, fights, abuse in family), fetal damage (alcoholic syndrome of the embryo), hematological problems (e.g increased MCV) and interaction with other drugs.

About alcohol addiction there is a questionnaire abbreviated CAGE in order to assess dependence. Answering yes in the following questions shows alcohol dependence:

Have you ever felt you should Cut down on your drinking?
Have people Annoyed you by criticizing your drinking?
Have you ever felt bad or Guilty about your drinking?
Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (Eye opener)?

However there is a more aggressive approach and some specialists believe that alcohol dependence occurs in men that had more than 4 drinks the same day, for at least 3 days in one year and women that had more than 3 drinks the same day, for at least 2 days in one year. That will make many of us alcoholic!

Men should consume less than 3 unites daily and women less than 2 units daily. 1 unit is 8 gr alcohol or ½ pint of beer (but strong beers may be as much as 1,75 units) or a small glass of wine or sherry or 1 measure of spirits (in Scotland 1 spirit is 1,2 units). One bottle of wine 12% is 9 units. Alcoholics need consultancy with a team of specialists including psychiatrists, psychologists, neurologists and GP. There are also special clinics for alcoholism. Moreover, Anonymous Alcoholics sessions are very helpful. There are also drugs such as acamprosate. Also vitamin thiamine (B1) is essential.

EXERCISE

Exercise is very important for preventing CHD and we all need regular exercise at least 30 minutes daily for at least 5 times per week. Children should follow at least 1 hour of moderate intensity exercise across the day, daily. Over exercising and championship have opposite effects. Important is to do specific aerobic exercise such as brisk walking and jogging, swimming, rowing, dancing etc. Regular exercise and diet help preventing CHD by decreasing the blood lipids (increase HDL and decrease LDL cholesterol) in people with hyperlipidaemia, decreasing the high blood pressure in hypertensive patients and decreasing high blood sugar (glucose) in diabetics.

Exercise also helps preventing cancer (e.g. colon, breast and prostate) and decreases the risk of hip fractures on patients with osteoporosis (here weight exercises help too). Exercise is essential for obese to lose weight. It also gives us a ‘high’ sensation because the body releases morphine – like substances (endorphins) decreasing the intensity of depression and anxiety and improving sleep (but not exercise before sleeping)! Exercise benefits include all ages. The cardiopulmonary benefits are big. There are simples ways such as walking to work, climbing stairs, cycling etc.

Furthermore, there are specific rehabilitation clinics that use anaerobic exercise for patients with cardio respiratory problems (e.g. after a MI or with CHD) and also for rheumatologic problems (arthritis). However people with any medical condition should never start exercising without first consulting their physician.

B) CEREBROVASCULAR ACCIDENT (CVA) (STROKE)

Cerebrovascular accident (CVA), known as stroke, is a very common, devastating condition, and major cause of disability. Causes of stroke include cerebral infraction (70% of cases) with atherothrombotic occlusion or from embolism from heart (from heart’s left atrium on patients with atrial fibrillation AF or from heart’s left ventricle after a MI or on a patient with heart failure).

19% of strokes are intracerebral or subarachnoid hemorrhage which causes direct neuronal injury and pressure phenomena.

Other rare causes of stroke are vasculitis, venous – sinus thrombosis (e.g. after an infection such as eye – periorbital cellulitis), sudden decrease on BP (e.g. cardiac arrest) and carotid artery dissection. TIA (Transient Ischemic Attack) or ‘mini stroke’ is a prodrome of stroke with neurological symptoms or transient blinding (amaurosis fugax) that resolve in less than 24 hours.

Ischemic stroke has the symptoms and signs of abrupt onset of hemiparesis (limb weakness, but not paralysis - palsy, in half side of the body, right or left), hemiplegia (palsy on 1 side of the body, same leg and hand, and same or opposite side of the face) monoparesis/ monoplegia (‘paresis’ is weakness and ‘plegia’ is palsy, both refer to one limb, hand or leg), paraparesis/ paraplegia (weakness or palsy on both limbs – legs) or quadriparesis/ quadriplegia (both hands and legs weakness or palsy), dysarthria (difficulty on speaking), vertigo (dizziness with rotational character), monocular (1 eye) or binocular (2 eyes) visual loss, visual field deficits and diplopia (double vision).

However, many times symptoms can distinguish ischemic from hemorrhagic stroke. Hemorrhagic stroke is usually (but not always) more abrupt and characterized by sudden onset of headache, nausea and vomiting, photophobia (fear of light), visual changes and loss of consciousness. A non contrast CT is the main initial image test for a CVA, however later a contrast CT, MRI and SPECT/ PET may be used.

Risk factors for stroke are increasing age, hypertension, DM, atrial fibrillation (AF, a heart arrhythmia often caused on pts with mitral valve stenosis or regurgitation), previous stroke or TIA, MI, smoking, alcohol, obesity, sedentary life style with low physical activity, artificial heart valves, vasculitis (e.g. SLE lupus, other reumatollogical/ collagen diseases), hyperviscosity syndromes (hematological diseases), medications, cocaine, and coagulation defects.

If doctor suspects that his patient may suffer from a stroke, then he must perform an emergency non contrast CT. In case of ischemic (but not in hemorrhagic) stroke patient can be treated with the thrombolytic r-TPA (used also in STEMI), but only if there aren’t any contraindications for it (e.g. bleeding disease, recent major surgery, anticoagulation the past 48 h, history of intracranial hemorrhage and so on), if patients is > 18 years with BP less than 185/110 old and if the patient has arrived less than 3 hours after the onset of the symptoms. The last condition minimizes the occasions of thrombolysis, because most patients visit the hospital later than 3 hours from the symptoms onset. In hemorrhagic CVA some cases (e.g. cerebellum hemorrhage) may be treated with surgery from a neurosurgeon.

STROKE PREVENTION

Prevention of stroke is essential and includes stopping smoking, avoiding excess alcohol, avoiding excess salt, do regularly exercise, have a healthy diet and controlling our weight. Patients with non hemorrhagic strokes are treated with antiplatelets such as aspirin (unless they take warfarin) which also prevents stroke on patients with TIAs. Dose is 50 – 300 mg od (once daily) for maintenance therapy. Dipyridamole 200 mg may be added to aspirin for additive effects. Clopidogrel 75 mg od is an alternative to aspirin intolerance. Of course patients must consult their physician for the drug therapy.

Patients with AF (atrial fibrillation, a arrhythmia) are anticoagulated with warfarin which is used to patient with rheumatic heart disease, prosthetic heart valve, and dilated cardiomyopathy. Also patients should control BP and target BP is less than 140/85, or less than 130/80 if diabetic. Also all patients with stroke should take a statin, such as simvastatin, regardless the baseline of cholesterol. In case of patients with stroke or TIA history and more than 70% carotid artery stenosis (from atherosclerosis), then surgical therapy (carotid endartyrectomy) or carotid artery angioplasty and stenting (if these patients don’t have any severe disability).

CONCLUSION

All what mentioned previously are preventive not only for CHD and cerebrovascular disease (CVA, stroke), but also for Diabetes Mellitus (DM), Hypertension, peripheral vascular disease (intermittent claudication) and many types of cancer.

It is said that our life expectance is directly proportional to out vessel age (which isn’t always proportional to our age). So patent vessels mean long life expectance. However modern medicine still offers help to patients with CHD, with drug therapy (β’ blockers, ACE inhibitors, statins, aspirin and other antiplatelets (such as Glycoprotein IIB/IIIA), angioplasty (PCI) and surgical ‘by pass’ (CABG).

But prevention is better than treating, as Hippocrates, the father of medicine, intoned. It is easier to prevent vascular diseases (CHD, CVA, peripheral vascular disease), and cancer by stop smoking, having annual checkup of our blood sugar and lipids (fats), by measuring and controlling our blood pressure (BP), by exercising regularly, by controlling hyperlipidaemia and DM, by having a healthy diet rich in fruits, vegetables, legumes (pulses) and fat fish, by taking daily a multivitamin, by using relaxation techniques (e.g., yoga or jogging) and by controlling our weight and avoid obesity. So the main stem of prevention of vascular diseases and cancer is smoking cessation, healthy diet, regular aerobic exercise and regular medical checkup (annually, if more than 35 years old).

NOTE