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What is Coronary Artery Disease (CAD)? Coronary artery disease or coronary heart disease are terms which signify the accumulation of atherosclerotic (cholesterol-rich) plaques in the coronary arteries. A heart attack characteristically results from progressive build-up followed by sudden rupture of an atherosclerotic plaque, with resultant blockage of coronary blood flow. Some individuals may have warning-sign symptoms in the lead-up to a first heart attack, most notably chest pain or chest heaviness on exertion, disproportionate shortness of breath with exercise, and palpitations or sweatiness in conjunction with chest heaviness. If present, these symptoms warrant urgent investigation. In many cases, however, there are no obvious symptoms present prior to a first heart attack. Coronary screening tests can provide valuable insights for those who are at elevated risk of coronary events. At-risk individuals include those with diabetes mellitus (two-fold increased risk of cardiovascular disease), high blood pressure, high cholesterol levels, cigarette smoking history, family history of cardiovascular disease, obesity, and/or chronic kidney disease.1 Commonly available screening or diagnostic tests for CAD largely fall into two categories: The benefits and limitations of commonly available tests are outlined below. Of note, blood tests such as troponin levels and resting electrocardiography (ECG) are not designed to detect CAD outside of the context of an acute heart attack and therefore are not reliable screening tests. View this post on Instagram A post shared by Almira Medical (@almiramedical.toronto) Coronary Artery Testing Modalities Functional Tests 1. Graded Exercise Stress Test (GXT) 2. Stress Echocardiogram (Exercise or Chemical) 3. Nuclear Medicine Myocardial Perfusion Imaging Anatomical Tests 1. CT Coronary Artery Calcium Score (CACS) 2. CT Coronary Angiography (CCTA) . Conventional Coronary Angiogram Almira Medical’s Approach In the long-term prevention of cardiovascular mortality, CAD screening can serve as a helpful adjunct to effective lifestyle changes and management of modifiable risk factors such as diabetes, hypertension, and high cholesterol. At Almira Medical we offer an annual, combined screening approach for coronary disease with graded exercise stress ECG (GXT) immediately followed by exercise stress echocardiogram. We prefer these screening modalities especially for asymptomatic individuals as they are non-invasive, can be performed safely and simultaneously in an office setting, and can be performed as often as needed without any concern for cumulative radiation exposure. Furthermore, exercise stress testing provides additional valuable information on an individual’s functional capacity, as measured by metabolic equivalents (METs), which correlates strongly with an individual’s cardiovascular mortality risk.5 If there are abnormalities or equivocal results based on initial screening tests, further testing such as with CT Coronary Angiography, nuclear imaging, or conventional (invasive) coronary angiography may be pursued on a case-by-case basis. When no concerns are identified, clearance for intensive aerobic activity can typically be granted, providing peace of mind. For those with negative stress tests we offer subsequent VO2 Max testing to further characterize an individual’s aerobic capacity and to inform an individualized exercise prescription. To learn more about Almira Medical’s comprehensive testing and preventative care programs, and to take the next steps to maximizing your potential longevity, contact us to today. References

Hypertension, the medical term for a diagnosis of high blood pressure, is a major risk factor for stroke, heart attacks, kidney failure, heart failure, blindness, amongst other significant issues. Left ignored, hypertension can cause irreparable damage. As a certified hypertension specialist and director of the Toronto Hypertension Clinic, I have educated and treated thousands of patients in achieving effective blood pressure control. View this post on Instagram A post shared by Almira Medical (@almiramedical.toronto) 1. What causes high blood pressure? High blood pressure in most individuals occurs because of a combination of factors as opposed to one single cause. Major contributing factors include increasing age, obesity, lack of exercise, excess salt consumption, ethnicity, strong family history of hypertension, excess alcohol, and poor sleep. A smaller subset of individuals (5-10%) have ‘secondary hypertension’, wherein an additional medical condition is causing blood pressure to be elevated. Such conditions include chronic kidney disease, obstructive sleep apnea, excess aldosterone hormone (primary aldosteronism), excess cortisol hormone (Cushing’s syndrome), kidney artery occlusion (renovascular hypertension), overactive and underactive thyroid conditions, and more. Testing for these conditions is guided by clinical suspicion and treatment resistance. 2. How do systolic and diastolic blood pressure change with age? For a blood pressure of 120/80mmHg, the systolic blood pressure (120) represents the maximum pressure an artery wall faces when blood is passing through. The diastolic blood pressure (80) is the pressure in the artery wall during relaxation, in-between heart beats. Controlling both numbers is important to prevent cumulative damage to the blood vessels over time. As depicted in the graph below, earlier in life women tend to have a lower systolic blood pressure than men, before rising faster on average from 45-55 years old. For an individual who is middle-aged, it is common to have a ‘diastolic-predominant’ form of hypertension. The diastolic blood pressure tends to reach a maximum around the age of 55 and gradually lowers in later life. By contrast, the systolic blood pressure continues to rise with age due to increased arterial stiffness, with arteries that are more calcified and less elastic. It is therefore common for an individual in their 80s or 90s to have a large difference between the systolic and diastolic blood pressure numbers. 3. What foods or diet best lowers blood pressure? Effective dietary changes should be a part of any hypertension treatment plan. The DASH diet (Dietary Approach to Stopping Hypertension) is a Mediterranean-type diet that has the best evidence for lowering blood pressure. It contains less-processed foods such as fruits and vegetables, low-fat dairy products, lean protein (fish and poultry instead of red meats), beans, nuts, and seeds. Sodium intake should be restricted to a maximum of 2000mg per day, with additional avoidance of high fat, highly-processed, and sugary foods. 4. What effect do alcohol, smoking, and caffeine have on blood pressure? Consuming a small amount of alcohol (e.g. 1-2 drinks per week) is unlikely to have a major impact on blood pressure, but when alcohol is consumed in higher amounts on a regular basis, cutting down can modestly improve blood pressure control, in addition to several other health benefits. Smoking typically causes a transient increase in blood pressure with cumulative effect if smoking consistently over the course of a day. Smoking is damaging to blood vessel walls, and has major long-term health consequences from cardiovascular, respiratory and cancer perspectives. Caffeine consumption in small to moderate amounts, such as with a daily coffee or tea, is safe for those with high blood pressure. 5. Is it safe to exercise with high blood pressure? Yes, exercise is safe and net beneficial for those with hypertension. Regular, moderately-intensity aerobic exercise has been shown to help lower blood pressure over time, amongst multiple other health benefits. It is a normal physiological response for blood pressure, similar to heart rate, to temporarily rise during exercise. This is not considered dangerous, and it is not necessary to monitor blood pressure during routine exercise. If you are experiencing dizziness with low blood pressure from your medication, consider temporary avoidance or modification of exercise activity to prevent loss of consciousness and/or injury. 6. What are the common symptoms of high blood pressure? Symptoms are not a reliable indicator of high blood pressure and most individuals with hypertension have no symptoms at all. A small subset of individuals may experience a band-like headache or in rare cases a nosebleed with blood-pressure spikes. Symptoms of low blood pressure often involve dizziness, fatigue, and light-headedness. 7. When should I go to the emergency department with high blood pressure? A hypertensive emergency is a systolic blood pressure that is greater than 180mmHg and/or diastolic blood pressure greater than 120mmHg with symptoms and signs that suggest acute organ damage: stroke or intracranial hemorrhage (brain bleed), a heart attack, aortic dissection, or pre-eclampsia / eclampsia. In all other situations (hypertensive urgency) there is no indication for rapid blood pressure lowering, and medication should be titrated gradually over weeks to months to allow time for the body to adapt and to avoid potential harm. Many individuals may notice a blood pressure ‘spike’ in the context of acute physical or psychological stress, with sympathetic nervous system activation and subsequent release of fight or flight hormones. Common situations of blood pressure spikes include physical injuries or pain flares, acute sleep deprivation, anxiety, panic attacks, amongst others. It is therefore important to recognize and address any alternate factors causing acute blood pressure elevation, allow time for stress to settle and further monitoring, and to treat the overall blood pressure average as opposed to outlier readings. 8. How often should I check my blood pressure? When making a hypertension diagnosis, starting or switching medications, or altering a medication dose, blood pressure should be measured more frequently: twice a day, once first thing in the morning and once just before bed. Monitoring frequency can be reduced during periods of blood pressure stability. To accurately measure your blood pressure, you should do so after being seated and relaxed for 5 minutes