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Summary of the course Nutrition and Cardiometabolic Diseases (HNH32106_2020_2)

Name: Summary of the course Nutrition and Cardiometabolic Diseases (HNH32106_2020_2)
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Course
Nutrition and Cardiometabolic Diseases (HNH32106)

Institution
Wageningen University (WUR)

Summary of all the lectures, spoc modules, assignments, practicals and some readings of the course Nutrition and Cardiometabolic Diseases (HNH32106_2020_2). Including figures. Update: including a hand-written summary at the end of the document

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cardiometabolic diseases
stroke
heart disease
embolism
diabetes
heart failure
tia

Institution
Wageningen University (WUR)
Education
Bachelor Voeding En Gezondheid
Course
Nutrition and Cardiometabolic Diseases (HNH32106)

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2020-2021

NUTRITION AND CARDIOMETABOLIC
DISEASES
HNH32106_2020_2

HOOGEVEEN, LIANNE
NUTRITION AND HEALTH
Period 2

,Index
INDEX ................................................................................................................................................................ 1
LECTURE 1: INTRODUCTION & CARDIOMETABOLIC DISEASES ...................................................................... 7
INTRODUCTION CVD .................................................................................................................................................................7
EPIDEMIOLOGIST’S BATHTUB ......................................................................................................................................................7
THE ATHEROTHROMBOTIC PROCESS ...........................................................................................................................................7
ACUTE CORONARY SYNDROME...................................................................................................................................................8
PERIPHERAL ARTERY DISEASE .....................................................................................................................................................8
THROMBO EMBOLISM .................................................................................................................................................................9
CEREBROVASCULAR DISEASE (STROKE) .......................................................................................................................................9
DIABETES................................................................................................................................................................................ 10
Gestational diabetes ...................................................................................................................................................... 10
LECTURE 2: CARDIOMETABOLIC RISK ........................................................................................................... 10
CARDIOMETABOLIC DISEASES PROCESS ................................................................................................................................... 10
RISK FACTORS ......................................................................................................................................................................... 11
HYPERTENSION ....................................................................................................................................................................... 11
BLOOD CHOLESTEROL ............................................................................................................................................................ 12
MENDELIAN RANDOMISATION STUDIES .................................................................................................................................... 13
DIABETES................................................................................................................................................................................ 13
PATHWAYS FOR CMD ............................................................................................................................................................. 13
RISK FACTORS VS RISK MARKERS ............................................................................................................................................... 14
Rothman’s pie model for causality ............................................................................................................................... 14
INDIVIDUAL RISK VS POPULATION RISK ...................................................................................................................................... 14
RISK MANAGEMENT ................................................................................................................................................................. 14
Framingham risk score................................................................................................................................................... 14
SCORE ............................................................................................................................................................................. 15
PREVENTION ........................................................................................................................................................................... 15
LECTURE 3: INTRO GROUP WORK.................................................................................................................. 15
Credibility ........................................................................................................................................................................ 15
Cohort vs RCT ................................................................................................................................................................. 16
Impact factors ................................................................................................................................................................. 16
LECTURE 4: Q&A SESSION LECTURES AND SPOC MODULES WEEK 1 .......................................................... 16
SPOC MODULES WEEK 1 ................................................................................................................................ 17
1.1.1 INTRODUCTION ............................................................................................................................................................. 17
1.1.4 TYPES OF CVD .............................................................................................................................................................. 17
Coronary heart disease .................................................................................................................................................. 17
Congestive heart failure ................................................................................................................................................ 18
Cerebrovascular disease/ stroke .................................................................................................................................. 18
Peripheral artery disease ............................................................................................................................................... 18
1.1.5 DIABETES MELLITUS....................................................................................................................................................... 18
Type 1 diabetes .............................................................................................................................................................. 19
Type 2 diabetes .............................................................................................................................................................. 19
Gestational Diabetes...................................................................................................................................................... 19
1.1.7 EPIDEMIOLOGIC MEASURES ........................................................................................................................................... 19
Prevalence ....................................................................................................................................................................... 19
Incidence ......................................................................................................................................................................... 19
Mortality ........................................................................................................................................................................... 20
DALY ................................................................................................................................................................................ 20
1.2.1 CARDIOVASCULAR RISK MANAGEMENT.......................................................................................................................... 20
SCORE risk chart ............................................................................................................................................................. 20

1

, Blood pressure................................................................................................................................................................ 20
Blood cholesterol ........................................................................................................................................................... 21
1.2.2 RISK FACTORS FOR CARDIOMETABOLIC DISEASE ............................................................................................................ 21
Cardiometabolic disease ............................................................................................................................................... 21
1.2.3 THINKING ABOUT RISK ................................................................................................................................................... 22
1.3.1 LIVING ENVIRONMENT ................................................................................................................................................... 22
READING: CUZI ....................................................................................................................................................................... 23
Adipose Tissue Insulin Resistance ................................................................................................................................ 23
Muscle insulin resistance ............................................................................................................................................... 23
READING: SZENDROEDI ................................................................................................................................. 23
Intramyocellular lipids .................................................................................................................................................... 23
Other organs and lipid accumulation .......................................................................................................................... 24
READING: MUNIYAPPA .................................................................................................................................. 24
Responsiveness and sensitivity ..................................................................................................................................... 24
Hyper insulinemic Euglycemia Glucose Clamp .......................................................................................................... 24
Oral Glucose Tolerance Test/ Meal Tolerance Test ................................................................................................... 25
Surrogates Derived from Fasting Steady-State Conditions (HOMA)........................................................................ 25
ASSIGNMENT: DIABETES MELLITUS PATHOPHYSIOLOGY ............................................................................ 26
SPOC MODULES WEEK 2 ................................................................................................................................ 28
3.1.1 INTRODUCTION TO DIABETES ......................................................................................................................................... 28
Types of diabetes ........................................................................................................................................................... 28
Control of blood glucose levels .................................................................................................................................... 28
Development of type 2 diabetes .................................................................................................................................. 28
3.1.2 ADIPOSE TISSUE ............................................................................................................................................................ 29
Adipose tissue depots in the abdominal region in relation to cardiometabolic health ......................................... 29
Ectopic lipid deposition ................................................................................................................................................. 29
Adipose tissue (dys)function in relation to the development of cardiometabolic diseases .................................. 30
3.1.3 INSULIN RESISTANCE ...................................................................................................................................................... 30
Insulin action ................................................................................................................................................................... 30
Insulin resistance ............................................................................................................................................................ 31
3.1.4 (EXHAUSTED) PANCREAS ............................................................................................................................................... 31
Functioning of the pancreas ......................................................................................................................................... 31
Beta cells ......................................................................................................................................................................... 32
Type 1 and 2 diabetes ................................................................................................................................................... 32
3.1.5 MEASURING INSULIN RESISTANCE ................................................................................................................................... 33
HOMA-index ................................................................................................................................................................... 33
OGTT................................................................................................................................................................................ 33
‘clamp’ ............................................................................................................................................................................. 34
LECTURE 5: PATHOPHYSIOLOGY / INSULIN RESISTANCE ............................................................................. 34
Diabetes .......................................................................................................................................................................... 34
Blood glucose regulation .............................................................................................................................................. 35
Insulin Resistance ........................................................................................................................................................... 35
Consequences ................................................................................................................................................................ 36
Role in Health and Disease ........................................................................................................................................... 36
Genetics & lifestyle ......................................................................................................................................................... 37
Pathophysiology of IR .................................................................................................................................................... 37
Adipokines & Lipotoxicity .............................................................................................................................................. 37
Ectopic lipids................................................................................................................................................................... 38
LECTURE 7: CARDIOVASCULAR SYSTEM, KIDNEYS & BLOOD PRESSURE .................................................... 38
CARDIOVASCULAR SYSTEM ...................................................................................................................................................... 38

2

, Heart ................................................................................................................................................................................ 38
Vessels ............................................................................................................................................................................. 39
Blood................................................................................................................................................................................ 40
Red blood cells ............................................................................................................................................................... 40
CARDIOVASCULAR DISEASE ..................................................................................................................................................... 41
Blood pressure................................................................................................................................................................ 41
Kidney .............................................................................................................................................................................. 42
Dietary Salt Intake and Renal Salt Handling ................................................................................................................ 43
Mutations ......................................................................................................................................................................... 43
LECTURE 8: PATHOPHYSIOLOGY OF THE HEART .......................................................................................... 43
CARDIAC MUSCLE ................................................................................................................................................................... 43
Different types of cells ................................................................................................................................................... 43
Structure .......................................................................................................................................................................... 44
Contraction ..................................................................................................................................................................... 44
ATRIAL FIBRILLATION ............................................................................................................................................................... 45
Atrial fibrillation .............................................................................................................................................................. 45
Risk factors ...................................................................................................................................................................... 45
Atrial remodelling........................................................................................................................................................... 46
Experimental models for AF .......................................................................................................................................... 47
Drug exploration (HSP) .................................................................................................................................................. 47
Role of PARP1 and NAD in AF ...................................................................................................................................... 48
TAKE HOME MESSAGE ................................................................................................................................................. 49
LECTURE 9: MOLECULAR MECHANISMS, INCLUDING OXIDATIVE STRESS AND MITOCHONDRIA .............. 49
ISCHEMIC HEART DISEASE (CARDIAC ISCHEMIA) ........................................................................................................................ 49
OXIDATIVE STRESS IN ISCHEMIA/REPERFUSION ......................................................................................................................... 49
ROS .................................................................................................................................................................................. 50
Therapeutic implications ............................................................................................................................................... 50
Sources of ROS ............................................................................................................................................................... 51
Oxidative phosphorylation ............................................................................................................................................ 51
MOLECULAR RESPONSE TO ISCHEMIA/HYPOXIA (HIF1) ............................................................................................................ 52
HIF1-mediated metabolic adaptations ........................................................................................................................ 52
HIF1- alpha ...................................................................................................................................................................... 53
PRACTICAL 1: GENE REGULATION ................................................................................................................. 54
PLURIPOTENT STEM CELLS (IPS) ............................................................................................................................................... 54
DNA – GENE REGULATION ...................................................................................................................................................... 54
Transcription factors....................................................................................................................................................... 55
NANOG ........................................................................................................................................................................... 56
SYNTHESIS .............................................................................................................................................................................. 56
Negative control ............................................................................................................................................................. 56
POST-TRANSLATION MODIFICATION........................................................................................................................................ 57
Western blot.................................................................................................................................................................... 57
PRACTICAL 2: HYPOXIA ................................................................................................................................. 58
PRACTICAL 3: HYPOXIA ................................................................................................................................. 58
Results .............................................................................................................................................................................. 59
INTRONS VS EXONS ................................................................................................................................................................. 59
ASSIGNMENT .......................................................................................................................................................................... 60
SPOC MODULES WEEK 3: ............................................................................................................................... 60
3.2.1 Inflammation ......................................................................................................................................................... 60
3.2.2 Endothelial (dys)function ..................................................................................................................................... 62
3.2.3 Blood lipids............................................................................................................................................................ 63

3

, 3.2.4 Ischemia and Reperfusion Injury ......................................................................................................................... 66
3.2.5 Blood pressure regulation ................................................................................................................................... 67
LECTURE 10: GENETIC FACTORS .................................................................................................................... 69
General principles of genetics and genetic epidemiology ....................................................................................... 69
Genetics of cardiometabolic diseases ......................................................................................................................... 69
GWAS .............................................................................................................................................................................. 70
How useful are GWAS results?...................................................................................................................................... 71
LECTURE 11: EPIGENETIC FACTORS............................................................................................................... 71
TRADITIONAL OBSERVATIONAL STUDY ..................................................................................................................................... 71
Mendelian randomisation studies ................................................................................................................................ 71
EPIGENETIC FACTORS .............................................................................................................................................................. 72
Epigenetics and DNA methylation ............................................................................................................................... 72
Epigenome wide-association study (EWAS) ............................................................................................................... 73
Nutrition and DNA methylation .................................................................................................................................... 73
Early life nutrition ............................................................................................................................................................ 73
LECTURE 12: FATTY ACIDS ............................................................................................................................. 73
DIFFERENT TYPES OF STUDIES IN NUTRITION RESEARCH ............................................................................................................ 73
FAT ABSORPTION, BLOOD LIPIDS AND LIPOPROTEINS, AND RISK OF CVD .................................................................................. 74
LDL-C concentration ...................................................................................................................................................... 74
HDL-C concentration ..................................................................................................................................................... 74
Triglycerides.................................................................................................................................................................... 74
EFFECTS OF PHYTOSTEROLS ON FAT METABOLISM ................................................................................................................... 75
TYPES AND SOURCE OF DIFFERENT FATTY ACIDS ...................................................................................................................... 75
ISO-CALORIC REPLACEMENT .................................................................................................................................................... 76
MAJOR FATTY ACID CLASSES ................................................................................................................................................... 76
SPOC MODULES WEEK 4: ............................................................................................................................... 77
2.2.3 DIETARY FATS AND HEALTH ........................................................................................................................................... 77
Introduction ..................................................................................................................................................................... 77
Types of fat ...................................................................................................................................................................... 77
Saturated fat in the media ............................................................................................................................................. 78
Partial hydrogenation..................................................................................................................................................... 78
4.1.1 INTRODUCTION TO OMICS ............................................................................................................................................. 78
Omics in cardiovascular disease, diabetes and obesity ............................................................................................ 79
Omics and nutrition........................................................................................................................................................ 79
4.2.1 INTRODUCTION TO GENETICS ........................................................................................................................................ 79
DNA ................................................................................................................................................................................. 79
Genes ............................................................................................................................................................................... 80
4.2.2 GENOME-WIDE ASSOCIATION STUDIES .......................................................................................................................... 80
4.2.3 DIET-GENE INTERACTIONS ............................................................................................................................................. 81
4.2.4 MENDELIAN RANDOMIZATION ....................................................................................................................................... 82
Complex diseases .......................................................................................................................................................... 82
Mendelian randomisation studies ................................................................................................................................ 82
4.3.1 DEVELOPMENTAL ORIGINS OF HEALTH AND DISEASE ..................................................................................................... 82
4.3.2 INTRODUCTION TO EPIGENETICS AND DNA METHYLATION ............................................................................................ 83
DNA Methylation ............................................................................................................................................................ 83
4.3.3 EPIGENOME-WIDE ASSOCIATION STUDIES ...................................................................................................................... 84
EWAS ............................................................................................................................................................................... 84
Limitations EWAS ........................................................................................................................................................... 84
4.3.4 EPIGENETICS AND CARDIOMETABOLIC DISEASES ........................................................................................................... 85
LECTURE 13: DIETARY GUIDELINES ............................................................................................................... 85

4

, HEALTHY DIET ......................................................................................................................................................................... 85
DIETARY GUIDELINES ............................................................................................................................................................... 86
Committees ..................................................................................................................................................................... 86
Prospective cohort study & randomised controlled trial ........................................................................................... 86
FBDGs .............................................................................................................................................................................. 87
ENVIRONMENTAL IMPACTS OF DIETS ........................................................................................................................................ 87
MEDITERRANEAN DIET ............................................................................................................................................................. 88
Benefits of the Mediterranean diet ............................................................................................................................... 88
What is the Mediterranean diet? .................................................................................................................................. 88
Healthy? ........................................................................................................................................................................... 88
LOW CARB DIET....................................................................................................................................................................... 88
LECTURE 14: NUTRITIONAL INTERVENTION STUDIES ................................................................................... 89
MEDITERRANEAN DIET ............................................................................................................................................................. 89
PREDIMED trial ............................................................................................................................................................... 89
OMEGA-3 FATTY ACIDS ........................................................................................................................................................... 89
VASCULAR HEALTH .................................................................................................................................................................. 90
Flow mediated dilation .................................................................................................................................................. 90
Polyphenols..................................................................................................................................................................... 91
Salt.................................................................................................................................................................................... 91
BIOMARKERS OF CARDIOVASCULAR HEALTH............................................................................................................................. 91
Arterial stiffness .............................................................................................................................................................. 91
Intima-media thickness .................................................................................................................................................. 92
DAIRY FOODS AND CVD ......................................................................................................................................................... 92
SALT AND CVD ...................................................................................................................................................................... 92
SPOC MODULES WEEK 5: ............................................................................................................................... 93
2.1.1 DIETARY GUIDELINES ..................................................................................................................................................... 93
Relative risk ..................................................................................................................................................................... 94
2.2.1 PROTEIN SOURCES ......................................................................................................................................................... 94
Protein sources ............................................................................................................................................................... 94
Meat ................................................................................................................................................................................. 95
Dairy ................................................................................................................................................................................. 95
Fish ................................................................................................................................................................................... 95
Plant food ........................................................................................................................................................................ 95
2.2.2 CARBOHYDRATES AND FIBRE ......................................................................................................................................... 95
Sugars .............................................................................................................................................................................. 95
Starches ........................................................................................................................................................................... 96
Indigestible carbohydrates (dietary fibres).................................................................................................................. 96
Glycaemic Index/ Load .................................................................................................................................................. 97
Fruit & vegetables .......................................................................................................................................................... 97
2.3.1 BEVERAGES ................................................................................................................................................................... 97
Coffee .............................................................................................................................................................................. 97
Tea.................................................................................................................................................................................... 97
Milk ................................................................................................................................................................................... 98
Sugar-sweetened beverages ........................................................................................................................................ 98
2.3.2 SALT ............................................................................................................................................................................. 98
Health effects .................................................................................................................................................................. 98
2.3.3 ALCOHOL...................................................................................................................................................................... 99
Ethanol ............................................................................................................................................................................. 99
Health effects .................................................................................................................................................................. 99
Apart from ethanol ......................................................................................................................................................... 99
Heavy drinking .............................................................................................................................................................. 100
5.1.1 DIETARY PATTERNS ...................................................................................................................................................... 100
Mediterranean diet....................................................................................................................................................... 100

5

, DASH-diet...................................................................................................................................................................... 100
Vegetarian diet ............................................................................................................................................................. 100
5.1.3 SUSTAINABLE DIETS ..................................................................................................................................................... 101
5.1.4 DIETS FOR CARDIOMETABOLIC PATIENTS ..................................................................................................................... 101
LECTURE 16: MICROBIOME .......................................................................................................................... 102
MICROBIOME ........................................................................................................................................................................ 102
Relationship with disease ............................................................................................................................................ 103
Interaction with nutrition and host .............................................................................................................................. 103
MICROBIOTA AND HOST INTERACTIONS ................................................................................................................................. 104
TMAO and CVD ............................................................................................................................................................ 104
Probiotics....................................................................................................................................................................... 104
LECTURE 17: VASCULAR DISEASE ................................................................................................................ 105
VASCULAR DISEASE à ATHEROSCLEROSIS ............................................................................................................................. 105
RISK FACTORS/ METABOLIC SYNDROME ................................................................................................................................. 105
TREATMENT OF OBESITY ........................................................................................................................................................ 105
Physical activity ............................................................................................................................................................. 105
Bariatric surgery ............................................................................................................................................................ 106
CHOLESTEROL ...................................................................................................................................................................... 106
Medication .................................................................................................................................................................... 106
PLATELET INHIBITION ............................................................................................................................................................. 107
HYPERTENSION ..................................................................................................................................................................... 107
INFLAMMATION ..................................................................................................................................................................... 107
SPOC MODULES WEEK 6: ............................................................................................................................. 107
4.4.1 GUT MICROBIOTA ....................................................................................................................................................... 107
SCFA .............................................................................................................................................................................. 108
Faecal Microbiota Transplantation ............................................................................................................................. 108
Cardiovascular diseases .............................................................................................................................................. 108
5.2.1 WHO IS IN CHARGE ...................................................................................................................................................... 109
HAND-WRITTEN SUMMARY.......................................................................................................................... 110

6

,Lecture 1: Introduction & cardiometabolic diseases
Introduction CVD
Cardiovascular disease (CVD) is a collective name for CHD, stroke, peripheral artery disease
etc. The cardiometabolic diseases are coronary heart disease, stroke (in the brain), chronic
kidney disease and diabetes type 2. These four diseases have different phenomena in
common: insulin resistance, inflammation, dyslipidaemia (high in lipids), hypertension and
vascular dysfunction.

Nowadays there are 415 million people worldwide with Diabetes Mellitus. The burden of
disease by cause is worldwide the highest for CVD. CVD causes more deaths (36%) than cancer
(26%) worldwide, but CVD does not cause the most deaths in The Netherlands anymore. The
CVD mortality rates have declined in The Netherlands. This is because in The Netherlands we
exercise more, and we smoke less. Also, the cholesterol control increased because of
medication. Small changes on population level have huge effects on the death rates. Now CVD
is number 2. Cancer mortality increased and is now the top 1. Only 2% of the people die from
diabetes, this is because the patients do not die from diabetes itself and diabetes is well
treatable. Mortality is not a good indicator for the burden of disease. People can be suffering
from a disease while they are alive. But you want to compare between countries, mortality is
mostly used.

Epidemiologist’s bathtub
The incidence is all the people in a certain timeslot
getting the disease, the prevalence are all the people
who have the disease at a certain timepoint, the
recovery is all the people who cured from the disease
and the mortality are all the people who died from
the disease.

Mortality figures does not show the whole story.
Changes in the burden of disease are related to
incidence, mortality, cure, population ageing etc. It
goes up due to population ageing, but it goes down when there is a cure.

Now there is more evidence that coffee might protect against cardiometabolic diseases. In
unfiltered coffee the coffee might increase the LDL-cholesterol. But when you use filtered
coffee, this is not the case and coffee
might protect you. It is not clear yet
why this is.

The atherothrombotic process
There are two types of blood clots:
- A thrombus: blood clot inside a
blood vessel or cavity of the
heart.

7

, - An embolus: blood clot that moves through the blood
stream until it ends up in a narrowed vessel and blocks the
circulation.

This process occurs in one of the coronary vessels that supply the
heart from oxygen. Atherosclerosis with a blood clot and a
spasm may result in a heart attack (= myocardial infarction).

Acute coronary syndrome
The acute coronary syndrome (ACS) comprises three diseases that
involve the coronary arteries:
- Unstable angina pectoris (AP): this is a pre-stage of the
myocardial infarction. The blood flow is obstructed sometimes
which can cause pain on the chest.
- ST evaluation myocardial infarction (STEMI). A STEMI or ST-
elevation myocardial infarction is caused by a sudden complete
blockage of a heart artery (coronary artery). This can also be seen
on the ECG.
- Non-ST evaluation myocardial infarction (NSTEMI). Non-STEMI is
usually caused by a severely narrowed artery, but the artery is not
completely blocked.

After a myocardial infarction (MI) heart failure often occurs. When you
have a thickened myocardium (because the heart has to work harder) it is
harder to pump blood to that parts of the heart. The Ejection Fraction
(EF) can be calculated = (SV/EDV) *100. SV is the stroke volume (the
amount of blood pumped from left ventricle per beat). EDV is the end-
diastolic volume. Heart failure is a chronic condition and can have a great
impact on life.

A healthy heart = 60% of more
A heart failure = 40% or less

Heart failure is also called decompensatio cordis, ‘insufficient heart’, congestive heart failure
(CHF). There are two types of heart failure in Left ventricular failure fluid builds up in the lungs
due to congestion of the veins in the lungs (dyspnoea). Right ventricular failure is when fluid
accumulates in the body, esp. in the legs and abdominal organs (e.g. liver).

Peripheral Artery Disease
In the Peripheral Artery Disease (PAD) you have narrowed arteries (for example in the ankles).
The arteries are narrowed by plaque. Intermittent claudication (this is a severe form of PAD) is
when you have muscle pain (ache, cramp, fatigue) caused by ischemia (lack of oxygen), mostly
in the calf muscle, which occurs during exercise and is relieved by a short period of rest. This is
also called “Window-shoppers disease” (because patients have to stop at shops because of
cramps) or “smoker’s legs”.

8

, With a diagnosis PAD you can measure the blood pressure in the ankle and branchial blood.
You first measure the blood pressure in the arm and then in the leg. When you divide to two,
the index is < or = to 0.9 when people have ABI.

Thrombo embolism
Thrombo embolism can be divided into two groups:
- Arterial (thrombo) embolism is in an artery in the leg or elsewhere. When it ends up in
the coronary artery it causes a myocardial infarction. It can also start in the carotid artery
or in the heart due to atrial fibrillation. There it can travel to the brain and cause an
ischemic stroke.
- Venous (thrombo) embolism (VTE) arises in a systemic vein, travels to the lung and
causes a pulmonary embolism. This can happen after a deep venous thrombosis (DVT).

Cerebrovascular disease (stroke)
A blocked brain artery can cause an Ischemic stroke (infarction), thrombus from elsewhere can
cause an Embolic stroke (infarction) and a ruptured brain vessel can cause a Haemorrhagic
stroke. A TIA is s mini stroke (ischemic or embolic) with symptoms that last less than 24 hours.

These three types of strokes can have different risk factors. A high blood pressure (because of
e.g. alcohol)/ decreased clot formation can cause a cerebral haemorrhage, a high cholesterol
can cause thrombotic stroke and increased saturated fat intake can cause the thrombotic and
embolic (ischemic) stokes. Plaque can be partially broken down in the early stages, but when
there is calcification this is not the case anymore. A
thrombus can be broken down with medication.

In a CT scan you can see the bleedings as white areas.
An infarction can be seen as a dark area. This is
important to know because of the treatment. The cause
of the strokes is different. For the Haemorrhage you
need to give blood pressure reduction medication and
for the infarction you can give aspirin to reduce the clot.

9

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