Heart and Artery Health

Definition

The term heart disease (coronary heart disease) is a term that describes many heart disorders, including high blood pressure, coronary artery disease, and clogging of the arteries.

Any number of diseases related to the heart and blood vessels can come under the umbrella of heart disease. Grouped together these diseases are the leading cause of death in the Western world.

The most common types of heart disease occur due to inadequate blood flow to the heart muscle.

NB: Obese people are at increased risk of due to their higher rates of hypercholesterolemia (high LDL cholesterol), diabetes and hypertension.

Description

Your heart is a living pump. It works to keep your blood moving and oxygenated. A network of blood vessels called coronary arteries supply blood and nutrients to your heart to keep it functioning in this way

There are three main coronary arteries – right (RCA), left anterior descending (LAD) and left circumflex artery (CX).

Each of the coronary arteries branches into smaller arteries that reach all the areas of your heart muscle.

The heart pumps ‘used’ blood through the lung capillaries where waste gas (carbon dioxide) is expelled and fresh oxygen is taken up. This fresh oxygenated blood is bright red and is pumped through the aorta (the main artery of the heart) into the capillaries, where nutrient and oxygen exchange within cells takes place. It then returns to the heart through veins.

Heart failure, for whatever reason, can be fatal. The heart is one of the hardest working organs in the body. It contracts and expands around 100,000 times a day, it supplies 96,000 kilometres of blood vessels and pumps in excess of 10,000 litres of blood around the body each day. This constant action is stressful and makes this system particularly vulnerable to damage and disease.

Heart disease is any disorder that affects the heart's ability to function in this normal way.

Some heart diseases can be present at birth (congenital); others develop as we grow and may be dependant on factors like genetics, diet (nutrition), the environment and toxins; others may be degenerative (or medical).

Problems can arise in the heart muscle, valves, or surrounding arteries. The most common form of heart disease is a narrowing or blocking of the coronary arteries (atherosclerosis). Following are examples of terms used to describe heart disease, followed by brief explanations of the most common problems:

Cardiovascular disease involves the heart and its two networks of blood vessels, the system which circulates the blood throughout the body and the system which circulates the blood through the lungs.

Coronary artery diseases (CAD) are diseases of the arteries that supply the heart muscle with blood. CAD is one of the most common forms of heart disease and the leading cause of heart attacks. It generally comes from blood flow obstructions. The most common cause of such obstructions is a condition called atherosclerosis. Coronary artery disease can cause other heart problems, such as chest pain angina and heart attack (myocardial infarction).

Coronary heart disease is also known as ischemic heart disease and is similar to coronary artery disease but a broader term that refers to both diseases of the arteries and their resulting complications, (chest pain, heart attacks and scar tissue).

Cardiomyopathy is a condition that includes all diseases of the heart muscle. Types of cardiomyopathy include ischemic, which is caused by loss of heart muscle from a heart attack; dilated, which means the heart is enlarged; hypertrophic, which means the heart muscle is thickened; and idiopathic or dilated idopathic, which means an enlarged heart without a known cause.

To the left is a normal heart - It has a complex grouping of outer muscles that work together to pump blood through the body. unhealthy heart

To the right is a weak, diseased heart - This is a heart with muscle disease. It looks larger than a healthy heart. A heart like this cannot pump blood properly.

Valvular heart disease is a disease of the heart valves, narrowing, leaking or improper closure.

Pericardial disease is a disease of the sac that encases the heart (pericardium). Fluid accumulation (pericardial effusion) and stiffness (constrictive pericarditis). These can occur alone or together.

Congenital heart diseases are forms of heart disease that develop before birth and affect the formation of the heart muscle or its chambers or valves. Some congenital heart defects may be apparent from the time of birth, while others may not be detected until later in life.

Heart failure is not a condition where the heart stops. It is a condition which describes the heart not being able to pump blood adequately to the body's organs and tissues. Vital organs don't get enough blood, and therefore oxygen, causing signs like shortness of breath, fluid retention and fatigue.

Blood vessels diseases
There are four types of blood vessels. They are:

Arteries that carry blood away from your heart and out to your body, delivering oxygen and nutrients.
Veins that carry deoxygenated blood back to your heart.
Capillaries that connect arteries and veins.
Lymphatics that carry this fluid back to the central circulatory system.

Types of blood vessel disorders include:

Arteriosclerosis and atherosclerosis

Arteriosclerosis is a condition in which the walls of your arteries become thick and stiff. Restricting blood flow to organs and tissues.

Atherosclerosis is the most common form of arteriosclerosis, referring to hardening of the arteries caused by accumulation of fatty deposits (plaques), often calcified, develop on the inside of the arterial walls and eventually cause blockages which lead to cardiovascular disease.

When the arteries of the heart narrow, you may experience chest pain or a heart attack.

Atherosclerosis is the result of the body's attempt to ‘repair’ injuries to the inside of the arterial walls. These injuries come about because of weaknesses in the walls and their exposed stress from the constant pumping action of the heart. Stress is increased by high blood pressure (hypertension) and emotional trauma.

The prevention of heart disease, heart attacks and strokes is synonymous with the prevention of atherosclerosis.

High blood pressure
Hypertension is the excessive force of blood pumping through your blood vessels due to restrictions. It affects 1 in every 4 people.

It is important to remember that hypertension is not a condition. It is a symptom of an underlying problem...ie. narrowing arteries. In societies that do not have high cardiovascular disease rates, high-fat diets and obesity, or stressful, fast modern lives, hypertension does not occur. It is a common symptom of underlying stress or body malfunction. If this cause is pinpointed and treated, the hypertension will naturally subside to normal levels.

Common underlying causes that bring about high blood pressure including lifestyle issues such as excess alcohol, caffeine, high salt intake, hormone therapies, stress, anxiety and lack of exercise, as well as conditions like diabetes, arteriosclerosis, high cholesterol, and many of the cardiac diseases listed here.

Although potentially life-threatening, because hypertension is a symptom of a condition it is very much preventable and curable. If left untreated, the symptom will of course worsen, putting undue pressure on the heart muscle and depleting blood vessel strength. After a period of time this will lead to serious cardiac disease such as stroke and heart failure.

Stroke
A stroke is a sudden loss of brain function. It occurs when blood flowing to the brain is interrupted (ischemia) or when blood vessels in the brain rupture (haemorrhage). Stroke can cause a number of neurological complications.

Aneurysm
An aneurysm is a bulge or weakness in the wall of an artery or vein. Aneurysms usually enlarge over time, and because of this they have the potential to rupture and cause life-threatening bleeding. Aneurysms can occur in arteries in any location in your body.

Peripheral arterial disease and claudication
Claudication is when you experience pain in your arms or legs during exercise, a symptom of peripheral arterial disease. It is a disorder in which the arteries supplying blood to your limbs become clogged or partially blocked. Pain or cramping is commonly the first sign.

Vasculitis
This refers to an inflammation of the blood vessels. Vasculitis can affect the arteries, veins or capillaries. The inflammation may impair general blood flow.

Venous incompetence
This is a condition in which blood flows the wrong way through your veins. Veins have tiny valves that are designed to promote blood flow in a forward direction, i.e. back to the heart. However, if you happen to be suffering from infection, inflammation, abnormal blood clotting, or even high-back pressure in pregnancy, the valves may become damaged, allowing blood to flow backward and ‘pool’ in your legs.

Venous imcompetence can lead to the development of such complications as prominent and painful varicose veins, skin changes, ulcers and swelling in your legs.

When venous incompetence occurs in your arms, you may experience pain and swelling in your arms and prominent veins may appear.

Venous thrombosis
This is the formation of a blood clot (thrombus) in a vein that may damage the vein or it’s valves. Clots that break off and travel in the bloodstream can lodge in the lungs, (pulmonary embolism). This type of clot may cause a stroke. Deep vein thrombosis is where a similar clot develops deep within a muscle.

Varicose veins
This is a condition in which your veins become twisted and enlarged. The veins are usually located on the backs of your calves or on the inside of your legs. When valves in your veins don't function properly, blood can accumulate in your legs, causing the veins to bulge and twist.

Lymphedema
This is an obstruction of the lymphatic vessels that causes an excessive build-up of fluid, resulting in swelling and pain.

Statistics

“Heart and blood vessel diseases kill more than 16 million people worldwide and account for 30% of total deaths each year.” (WHO)

Cardiovascular diseases are the number one killer of both women and men.

US Facts

More than 1.5 million heart attacks occur every year in the US.
50 million Americans have high blood pressure.
Every 20 seconds an American suffers a coronary event. Every 34 seconds someone dies from heart disease.

European Facts

CVD kills 4 million Europeans each year. It's the No 1 cause of death.
1 British adult dies from heart disease every 3 minutes.
Strokes claim over 70,000 UK lives each year.

Cardiovascular disease is very much a disease of Western civilization.

Causes

Decades of research show that poor lifestyle choices, beginning in childhood, are the main causes of cardiovascular disease. Ongoing factors, such as poor diet, nutritional deficiency, lack of exercise, poor fluid intake and increased toxicity and stresses form a recipe for circulatory disaster.

All of the above are major risk factors. More specifically, high blood pressure - hypertension (itself a result of any/all of the above), tobacco use, increased intake of saturated fats, lack of essential antioxidants (excessive exposure to free radicals via pesticides, chlorinated water, air pollutants and other toxic chemicals, for example, is a strong risk factor for cardiovascular disease), elevated blood cholesterol, convenience lifestyle (i.e. reduced exercise) and genetic predisposition.

All these and more lead to increased stress factors, obesity and diabetes... in turn leading to heart attacks, strokes, artherosclerosis, and more

NB: Stress not only raises the blood pressure and constricts the arteries, it also generates large quantities of adrenalin which the body converts to adrenochrome - a potent free radical.
The more ‘risk factors’ you have, the more likely you are to develop heart disease. All of these factors, bar genetic factors, can be changed and treated, even genetic risks can be modified with proper treatment.

Blood pressure can vary with activity and age, but a healthy adult who is resting generally has a systolic pressure reading between 120 and 130 and a diastolic pressure reading between 80 and 90 (or below).
Free radical activity plays a major role in the development and progression of atherosclerosis in particular, through oxidized lipoproteins and through direct attacks on the DNA of the arterial wall cells.

As the body attempts to repair damage to arterial walls, smooth-muscle cells (at the centre of the repair) themselves accumulate cholesterol and oxidized lipoproteins, and may begin to undergo calcification. As these deposits grow the inside opening of the artery begins to narrow, eventually create a blockage. If the blockage is in the coronary arteries angina pectoris may develop, or a heart attack may occur. If it is in the brain a stroke may occur, and if the blockage is in the legs intermittent claudication (pain or fatigue in arms and legs due to poor supply of oxygen to the muscles) may be experienced.

Iron has more recently been implicated in heart disease development. Researchers at Harvard University have concluded that it is not the overall iron intake that increases heart attack risks, but rather the specific intake of iron from red meats – potentially increasing your disease risk by up to 38%!

Cholesterol levels, and more specifically high LDL (low density lipoprotein) levels, are strong risk factors for cardiovascular disease, especially for men. Too much LDL cholesterol in the blood causes plaque to form on artery walls (the beginning of atherosclerosis). When this occurs arteries that supply blood to the heart get blocked (see description above) and you become at high risk of a heart attack. (See our Cholesterol section for more info)

Cholesterol is a soft, buttery substance. If the only build-up on the inside of the arteries were cholesterol, it would not get hard and the flow of blood would wash away the stuff. But, when that cholesterol gets mixed up with calcium the combination of the two becomes hard. That is why the honest term, used before the drug companies started fiddling with the facts, was 'hardening of the arteries'.

Homocysteine is an amino acid in the blood, high levels of which can significantly increase the risk of cardiovascular disease.

Mercury toxicity and Helicobacter pylori bacterium infection are potent initiators of coronary heart disease.

Diabetes
It is not often well understood that heart problems are actually a consequence (and symptom) of diabetes, and are the leading cause of death among diabetes sufferers, especially in adult-onset, or Type II diabetes. The American Heart Association estimates that 65% of patients with diabetes die of some form of cardiovascular disease. (See our Diabetes section for more info…)

Obesity…Being overweight is, alongside diabetes, the leading cause of increased cholesterol levels, high blood pressure and coronary artery disease. Obesity increases your chances of developing all these risk factors in fact, as well as putting unnecessary strain on many other organs.

NB: Just from these short summaries you may be beginning to notice how all these conditions clearly interlink with one another…

Smoking, as well as increasing your risk of lung cancer, increases risks of heart disease and peripheral vascular disease. More than 400,000 deaths in the US alone occur each year because of the straining effects this habit has on the heart and blood vessels.

Research has shown that smoking increases the heart rate, tightens major arteries and can create irregularities in the timing of heartbeats, all of which make your heart work harder.

Although nicotine is the main active agent in cigarette smoke, other chemicals and compounds like tar and carbon monoxide are harmful to your heart too and lead to plaque build-up and injury to the vessel walls.

Inflammation…C-reactive protein (CRP) is a substance found in blood that is a marker for inflammation in the body. High levels of this protein are associated with an increased risk of heart disease and low levels with a low risk.

Studies suggest that CRP levels may even be a more important indicator of heart disease risk than high LDL cholesterol!In an eight-year study involving 27,939 women led by Paul Ridker, MD, director of the Center for Cardiovascular Disease Prevention at Brigham and Women's Hospital in Boston, more than half of the women who eventually developed heart disease had high CRP levels even though their LDL levels were not considered high.
The New England Journal of Medicine
November 2002

A Cleveland Clinic study found ultrasound evidence that clogged coronary arteries had not gotten worse among 502 patients who were most successful at lowering their CRP levels.
The New England Journal of Medicine
January 2005

A recent study at showed that as fitness levels go down, CRP levels go up.
Johns Hopkins
To help lower CRP levels it is recommended to concentrate on an anti-inflammatory diet, plus Omega 3 DHA fish oil supplements and anti-inflammatory and antioxidant supplement ingredients which include methylating agents to reduce homocyteine.

Finally, other indirect factors include…

Physical Inactivity - People who are inactive have a greater risk of disease leading to a heart attack. Exercise burns calories, helps to control cholesterol and diabetes, and may help to lower blood pressure. Exercise also strengthens the heart muscle itself and makes the arteries more flexible. Even moderate exercise is helpful if done regularly.

Genetics - Risk factors (high blood pressure, diabetes and obesity) may be passed from one generation to another…

Stress - We all deal with stress differently. How much and in what way stress affects us can vary from person to person. During times of stress the nervous system releases extra hormones (e.g. adrenaline). These hormones can raise blood pressure and injure the lining of the arteries. When the arteries heal the walls may harden or thicken, making is easier for plaque to build up.

Stress also increases the amount of blood clotting factors that circulate in your blood. Clots may block an artery already narrowed by plaque, resulting in a heart attack.

Nutritional deficiency and toxicity
It is never too late to begin improving heart health. By eliminating risk factors and properly managing your health, you can greatly reduce your risk of heart disease, and even begin to heal disease that is already present.

Most people become vulnerable to these diseases because of a weakened immune system and systemic and organ-related weaknesses as a result of inadequate nutrition. This more often than not starts in early life, but continues to reduce health throughout life. Nutritional deficiencies, chemical and environmental toxicities are the major reason for the accentuation of most, if not all of the above risk factors.

Diagnosis

Sadly, in most cases the first indication of cardiovascular disease is an actual acute heart event. This is because many of the underlying symptoms are either mistakenly considered a consequence of some other condition or disease, or they are simply misdiagnosed.

On most occasions symptoms are not noticed by the patient until such time that they cause a major condition….often being put down to another unrelated condition, being ‘run down’, or being under ‘stress’.

Angina pectoris (chest pain) and stroke (cerebral infarction) are the most common physical symptoms that are first noticed.

If prior symptoms are realised, techniques and equipment can be used to confirm a diagnoses:

Electrocardiograms are tests particularly indicative for people with high risk factors (smoking, diabetes, obesity and hypertension). They can even show if a patient has already suffered a mild heart attack without noticing it.

Radioisotopes help to spot blood flow problems.

An Echocardiography is useful to evaluate the heart's performance.

Position emission tomography (PET scanning), CT scanning and magnetic resonance spectroscopy are also commonly used.

Surgery

Coronary arteriography is an invasive technique used to determine the extent and location of blockages in coronary arteries. It is only used prior to heart surgery such as angioplasty or bypass surgery.

As in all cases of potentially chronic illness, a thorough history - medical and genetic - should be taken, along with lifestyle, nutritional and dietary implications, and any other factors to help determine risk and current health statistics.

Signs & Symptoms

As mentioned above, often symptoms are not noticeable until an actual stage of disease has already manifested. Some symptoms associated with coronary artery disease may be more pronounced however. Such signs include:

Angina (chest pain) - This is the most common symptom, resulting from the heart intermittently not getting enough blood or oxygen. The intensity of the pain may vary from person to person.

Typical chest pain is felt under the sternum and is characterised by a heavy feeling, or a feeling of the chest being squeezed. Pain may also radiate to the shoulders, neck, or arms. It is often precipitated by exertion or emotional stress and is relieved by rest.

Women may also have a tendency to experience some areas of swelling - the ankles and legs for example – plus stomach upset, dizziness, rapid heartbeats, shortness of breath and chronic fatigue.

Shortness of breath – This can be a symptom of congestive heart failure (among many other things). The heart may be weak due to lack of blood and oxygen, resulting in shortness of breath accompanied by swollen feet and ankles too due to the reduced circulation.

When A Heart Attack is experienced you may experience intense chest pain that can be acute or last for a more extended period of time. There may be a sensation of pressure, burning, tightness, heaviness, or squeezing behind the breastbone. Pain in the left arm or jaw and of course laboured breathing also may occur. Alternatively pain may be more diffuse, spreading to the shoulders, neck, arms, abdomen and even back. Pain my come and go, feeling like a heaviness or burning sensation in the chest rather than intense pain.

Some victims of coronary heart disease experience none of these symptoms, while others experience them at varying levels. Initial emergency treatment is often recommended, such as the chewing of a regular strength adult Aspirin to inhibit blood clotting in the affecting coronary artery.

Stroke symptoms include a number of warning signs:

Changes in vision
Leg, arm, or face weakness
A sudden, severe headache
Changes in speech and hearing
Unsteadiness or unexplained dizziness
Nausea, vomiting, or drowsiness

Symptoms may be especially noticeable on one particular side of the body.

Heart Failure symptoms may include:

Fatigue
Shortness of breath
Persistent coughing
Swelling of the feet, ankles, legs, or abdomen.

Symptoms may continue for years unnoticed as the heart weakens.

Treatment

As is the case with most degenerative diseases there are two avenues of treatment - conventional (allopathic) and alternative (natural) treatment.

Conventional medicine employs surgery and drugs to treat the symptoms of cardiovascular disease.

On the other hand, alternative methods concentrate on the whole body and underlying problem to bolster the body's natural healing powers and focus on removing the actual cause of the disease rather just treating the symptoms.

Conventional medicine helps to diagnose and treat acute, life-threatening events, but natural ‘wholistic’ methods are more gentle, have far fewer side effects and are capable of actually reversing heart disease and regaining full health as well as working to protect and prevent disease occurring in the first place.

Conventional Treatments

Lifestyle changes are of course the first line of prevention and treatment of cardiovascular disease.

Conventional medicine recommends medical interventions ranging from drugs to surgery. For example, a bypass operation may be performed to reduce a person's risk of a heart attack, or to try to help stop any further heart attacks from taking place. When this operation is performed a blood vessel from another body area is used to ‘re-route’ blood around the blocked artery.

Many prescription medications are used every day to help prevent or control coronary heart disease (CHD). However, if medications are needed lifestyle changes still must be undertaken for results to take effect.

Common Drugs used to treat CHD include:

Aspirin helps to lower the risk of a heart attack for those who have already had one. It also helps to keep arteries open in those who have had a previous heart bypass or other procedure.

However, because of its side effects aspirin is not approved by the Food and Drug Administration in the US for preventing heart attacks in healthy individuals with careful assessment.

Some of the most common aspirin side effects are stomach pain, heartburn, nausea and vomiting. (An aspirin overdose or higher dosage than recommended can cause very serious health issues).

Long-term use of Aspirin has shown to cause gastrointestinal tract complications, including micro-bleeding and ulcers. There is also a risk of haemorrhagic stroke.

ACE (angiotensin converting enzyme) inhibitors stop the production of a chemical that makes blood vessels narrow and is used to help control high blood pressure and help heal damaged heart muscle. It may be prescribed after a heart attack to help the heart pump more efficiently. It is also used for heart failure cases.

Side effects may include a dry cough, headache and dizziness. ACE inhibitors may also cause elevated amounts of potassium. More rare side effects can include skin rashes, kidney problems, and swelling of the face, lips and throat

Example drugs: Benazepril (Lotensin), Captopril (Capoten), Enalapril (Vasotec), Fosinopril (Monopril), Lisinopril (Prinivil, Zestril), Moexipril (Univasc), Perindopril (Aceon), Quinapril (Accupril), Ramipril (Altace), Trandolapril (Mavik).

Angiotensin II Receptor Blockers
Angiotensin II constricts blood vessels and causes the kidneys to retain more fluid. The main function is to increase blood pressure. Angiotensin II receptor blockers (ARBs) inhibit the effects of angiotensin II by blocking the receptor, thereby reducing constriction and helping to reduce blood pressure.

ARBs also help to minimize over-exertion of the heart muscle and help prevent progression to heart failure. ARBs are mainly used when ACE inhibitors are not tolerated by the individual.

Side effects may include headache, lightheadedness, nasal congestion, back and leg pain, diarrhea, rash, indigestion and insomnia. More rare side effects may include kidney failure, liver failure, allergic reaction, reduced white blood cell count and swelling of tissues (angioedema).

Because ARBs can cause birth defects they are not recommended if pregnant or planning to become pregnant.

Example drugs: Candesartan (Atacand), Eprosartan (Teveten), Irbesartan (Avapro), Losartan (Cozaar), Olmesartan (Benicar), Telmisartan (Micardis), Valsartan (Diovan).

News
Do angiotensin II receptor blockers increase MI risk, or do they not?
A pair of articles in ‘Circulation’ magazine/journal discusses the controversy over whether or not angiotensin-II-receptor blockers (ARB) result in a paradoxical increase in risk of myocardial infarction (MI), despite reducing blood pressure. (Also raised, in a BMJ editorial in 2004.)

Suggesting that these drugs do increase the risk of MI argue firstly that in general, clinical trials with ARB have not shown the reduction in MI risk that could have been expected given the drop in blood pressure that they achieve. They discuss the major trials involving ARB, and also the various (and discordant) meta-analyses that have been carried out….

Antiplatelets
Blood clots can block blood flow to the heart or brain, causing a heart attack or stroke. Antiplatelet medications work by preventing platelets from sticking together to form blood clots to reduce the risk of a heart attack or stroke occurring, specifically in people who have already had a heart attack or stroke, or who have poor circulation that causes pain.

Possible side effects include allergic reaction (sneezing, respiratory congestion, swelling of throat, restricted breathing, itching or skin rashes), nausea, indigestion or stomach pain,
unusual bleeding or bruising, ringing in ears (tinnitus), bloody urine, convulsions or seizures (rare).

Example drugs: Clopidogrel (Plavix), Ticlopidine (Ticlid).

Beta blockers slow the heart and make it beat with less force, so blood pressure drops and the heart works less hard. It is used for high blood pressure, chest pain and to prevent a repeat heart attack.

The most common side effects are cold hands and feet, tiredness and sleep disturbance (nightmares). Less common side effects include, impotence, dizziness, wheezing, digestive tract problems, skin rashes and dry eyes.

Example drugs: Acebutolol (Sectral), Atenolol (Tenormin), Atenolol Injection (Tenormin Injection), Bisoprolol (Zebeta), Carteolol (Cartrol), Metoprolol ER (Toprol XL), Metoprolol Oral (Lopressor), Nadolol (Corgard), Pindolol (Visken), Propranolol (Inderal), Propranolol ER (Betachron ER, Inderal LA, Innopran XL), Timolol Oral (Blocadren).

News
Guidelines issued by the NHS drugs watchdog have given new advice on which medicines should be used to treat high blood pressure. They recommend that beta-blockers should no longer be routinely used, expect in special situations….

There is also increasing evidence that the most frequently used beta-blockers can carry a higher risk.

Nitrates (including nitroglycerine) – relax blood vessels and stop chest pain.

Side effects include a feeling of pulsating fullness in the head (most common side effect) or a headache, a drop in blood pressure, which can cause dizziness or a burning sensation under the tongue.

Example drugs: Isosorbide Dinitrate, Sublingual and Chewable (Isordil, Sorbitrate), Isosorbide Mononitrate (Imdur, Ismo, Isotrate ER, Monoket), Nitroglycerin ER (Nitroglyn),
Nitroglycerin Ointment (Nitro-Bid Ointment, Nitrol), Nitroglycerin Skin Patches (Deponit, Minitran

Health conditions