CVD Definitions and Statistics April 2010

CVD Definitions and Statistics April 2010 - Cardiovascular...

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Unformatted text preview: Cardiovascular Epidemiology and Prevention and Nathan D. Wong, PhD, FACC, FAHA Professor and Director, Heart Disease Professor Prevention Program, Division of Cardiology, University of California, Irvine Cardiology, President, American Society of Preventive President, Cardiology Cardiology Agenda Agenda • April 26 x x x CVD definitions, US and Global Statistics Historical perspective and risk factor overview Screening for subclinical atherosclerosis • May 3 x x x Dyslipidemia Metabolic Syndrome/Diabetes Behavioral Issues (Nutrition, Obesity, Physical Behavioral Activity, Tobacco, Psychosocial Factors) Activity, • May 10 x x Hypertension Chronic Kidney Disease CVD Prevention Guidelines Cardiovascular Epidemiology: Definitions, Concepts, Historical Perspectives and Statistics Statistics 500,000 409,867 454,613 Deaths 400,000 290,422 300,000 268,890 200,000 76,375 62,435 100,000 68,498 36,538 41,434 51,040 0 A B C D E Males A B D F Females A Total CVD B Cancer C Accidents D Chronic Lower Respiratory Diseases Diseases E Diabetes Mellitus F A of death for all and other major causeslzheimer’s Disease males and CVD females (United States: 2005). Source: NCHS. C Per 100,000 Population 200 140.9 150 110.0 100 44.0 50 60.7 41.5 40.0 23.4 32.8 0 Coronary Heart Disease Stroke White Females Lung Cancer Breast Cancer Black Females Age-adjusted death rates for CHD, stroke, lung and breast cancer for white and black females (United States: 2005). cancer Source: NCHS and NHLBI. Deaths i n Thousands 1,000 831 800 560 600 400 242 200 2 5 21 48 50 138 81 101 120 315 165 85 0 <45 45-54 55-64 65-74 75-84 Ages CVD Cancer CVD deaths vs. cancer deaths by age. CVD (United States: 2006). Source: NCHS. (United 85+ Total Clinical Manifestations of Atherosclerosis • Coronary heart disease – Stable angina, acute myocardial infarction, sudden Stable death, unstable angina death, • Cerebrovascular disease – Stroke, TIAs • Peripheral arterial disease – Intermittent claudication, increased risk of death Intermittent from heart attack and stroke from American Heart Association, 2000. Definitions Definitions • CORONARY ARTERY DISEASE (CAD) or CORONARY CORONARY HEART DISEASE (CHD) (often broadly referred to as ISCHEMIC HEART DISEASE (IHD): primarily myocardial infarction and sudden coronary death, broader definition may include angina pectoris, atherosclerosis, positive angiogram, and revascularization (perceutaneous coronary interventions, or PCI such as angioplasty and stents) PCI • CARDIOVASCULAR DISEASE or CVD CARDIOVASCULAR includes CHD, cerebrovascular disease, peripheral vascular disease, and other cardiac conditions (congenital, arrhythmias, and congestive heart failure) arrhythmias, Definitions (cont.) Definitions • SURROGATE MEASURES include: carotid SURROGATE intimal medial thickness (IMT), coronary calcium, angiographic stenosis, brachial ultrasound flow mediated dilatation (FMD) ultrasound • Hard endpoints include myocardial Hard infarction, CHD death, and stroke infarction, Coronary Heart Disease 7 4 Stroke 14 HF* 51 7 17 High Blood Pressure Diseases of the Arteries Other Percentage breakdown of deaths from cardiovascular diseases (United States: 2006) * - Not a true underlying cause. Not Source: NCHS. Source: Deaths i n Thousands 1,000 800 600 400 200 0 00 10 20 30 40 50 60 70 80 90 00 06 Years Deaths from diseases of the heart (United States: 1900–2006) Deaths (United Note: See Glossary for an explanation of “Diseases of the Heart.” Source: NCHS. Source: Deaths in Thousands 550 500 450 400 350 79 80 85 90 95 00 Years Males Females CVD disease mortality trends for males and females CVD (United States: 1979-2006). United Source: NCHS and NHLBI. 06 Discharges in Millions 7 6 5 4 3 2 1 0 70 75 80 85 90 95 00 06 Years Hospital discharges for cardiovascular diseases. (United States: 1970-2006). Note: Hospital discharges include people discharged alive, dead and status unknown. Source: NCHS and NHLBI. Source: Procedures in Thousands 1400 1200 1000 800 600 400 200 0 79 80 85 90 95 00 06 Years Catheterizations PCI Pacemakers Bypass Carotid Endarterectomy Trends in Cardiovascular Operations and Procedures (United States: 1979-2006). Source: NCHS and NHLBI. Source: (United Note: In-hospital procedures only. Bil l i ons of Dol l ars 200 177.1 160 120 73.7 80 76.6 39.2 40 0 Coronary Heart Disease Stroke Hypertensive Disease Heart Failure Estimated direct and indirect costs (in billions of dollars) of major cardiovascular diseases and stroke (United States: 2010). Source: NHLBI. Source: 17.1 18 16 13.5 Percent of Population 14 12 10 7.8 8 7.6 6 2.9 4 2 0.2 0.3 0.9 0 20-39 40-59 60-79 Men 80+ Women Prevalence of stroke by age and sex (NHANES: 2005-2006). Prevalence Source: NCHS and NHLBI. Source: I n c i d e n c e p e r 1 0 0 ,0 0 0 250 200 226 219 181 156 150 100 50 20 24 42 44 6 7 11 11 0 Ischemic White '93-94 Intracerebral Subarachnoid hemorrhage hemorrhage White '99 Black '93-94 Black '99 Annual age-adjusted incidence of first-ever stroke, by race. Inpatient plus out-of-hospital ascertainment. (GCNKSS: 1993-94 and 1999). Source: Stroke 2006;37;2473-2478. Source: Percent of Population 16 14 12 10 8 6 4 2 0 13.8 12.2 9.3 4.8 2.2 0.1 0.2 20-39 1.2 40-59 Men 60-79 Women Prevalence of heart failure by age and sex (NHANES: 2005-2006). Source: NCHS and NHLBI. 80+ D ischarges in Thousands 700 600 500 400 300 200 100 0 79 80 85 90 95 00 06 Years Male Female Hospital discharges for heart failure by sex. (United States: 1979-2006). Source: NHDS/NCHS and NHLBI. Source: (United Note: Hospital discharges include people discharged alive, dead and status unknown. and Development of Atherosclerotic Plaques Fatty streak Normal Lipid-rich plaque Foam cells Fibrous cap Thrombus Ross R. Nature. 1993;362:801-809. Lipid core PDAY: Percentage of Right Coronary Artery Intimal Surface Affected With Early Atherosclerosis Intimal 30 Men Raised lesions Fatty streaks 30 20 Intimal surface (%) 20 10 Women 10 0 30 0 15-19 20-24 25-29 30-34 White 30 20 20 10 15-19 20-24 25-29 30-34 White 10 0 0 15-19 20-24 25-29 30-34 Black Age (y) PDAY= Pathobiological Determinants of Atherosclerosis in Youth. Strong JP, et al. JAMA. 1999;281:727-735. 15-1920-2425-2930-34 Black Most Myocardial Infarctions Are Caused Most by Low-Grade Stenoses Pooled data from 4 studies: Ambrose et al, 1988; Little et al, 1988; Nobuyoshi et al, 1991; and Giroud et al, Pooled 1992. 1992. (Adapted from Falk et al.) Falk E et al, Circulation, 1995. Coronary Remodeling Progression Compensatory expansion maintains constant lumen Normal vessel (Adapted from Glagov et al.) (Adapted Glagov et al, N Engl J Med, 1987. Glagov Engl Minimal CAD Moderate CAD Expansion Expansion overcome: overcome: lumen narrows Severe CAD Atherosclerotic Plaque Rupture and Atherosclerotic Thrombus Formation Thrombus Intraluminal thrombus Growth of thrombus Blood Flow Intraplaque thrombus Adapted from Weissberg PL. Eur Heart J Supplements 1999:1:T13–18 Lipid pool Features of a Ruptured Atherosclerotic Plaque • Eccentric, lipid-rich • Fragile fibrous cap • Prior luminal obstruction < 50% • Visible rupture and thrombus Constantinides P. Am J Cardiol. 1990;66:37G-40G. Vulnerable Versus Stable Atherosclerotic Plaques Vulnerable Plaque Lumen Fibrous Cap Lipid Core •Thin fibrous cap •Inflammatory cell infiltrates: proteolytic activity •Lipid-rich plaque Stable Plaque Lumen Lipid Core Fibrous Cap Libby P. Circulation. 1995;91:2844-2850. •Thick fibrous cap •Smooth muscle cells: more extracellular matrix •Lipid-poor plaque Correlation of CT angiography of the coronary arteries with intravascular ultrasound illustrates the ability of MDCT to demonstrate calcified and non-calcified coronary plaques (Becker et al., Eur J Radiol 2000) Non-calcified, soft, lipid-rich plaque in left anterior descending artery (arrow) (Somatom Sensation 4, 120 ml Imeron 400). The plaque was confirmed by intravascular ultrasound (Kopp et al., Radiology 2004) Concept of cardiovascular “risk factors” “risk Age, sex, hypertension, hyperlipidemia, smoking, diabetes, (family history), (obesity) Kannel et al, Ann Intern Med 1961 Major Risk Factors Major • • • Cigarette smoking (passive smoking?) Elevated total or LDL-cholesterol Hypertension (BP ≥ 140/90 mmHg or on Hypertension 140/90 antihypertensive medication) antihypertensive • Low HDL cholesterol (<40 mg/dL)† • Family history of premature CHD – CHD in male first degree relative <55 CHD years years – CHD in female first degree relative <65 CHD years years • Age (men ≥ 45 years; women ≥ 55 years) Age 45 † HDL cholesterol ≥ 60 mg/dL counts as a “negative” risk factor; its presence removes one risk factor from the total count. Other Recognized Risk Factors Factors • Obesity: Body Mass Index (BMI) – Weight (kg)/height (m2) – Weight (lb)/height (in2) x 703 • Obesity BMI >30 kg/m2 with overweight Obesity defined as 25-<30 kg/m 2 defined • Abdominal obesity involves waist Abdominal circumference >40 in. in men, >35 in. in circumference 40 35 women women • Physical inactivity: most experts Physical recommend at least 30 minutes moderate activity at least 4-5 days/week activity ___________________________________________________________ _ Lifetime Risk of Coronary Heart Disease in the Framingham Study in ______________________________________________________________ Men Men At age 40 years: 48.6% At age 70 years: 34.9% Women Women 31.7% 24.2% _________________________________________________________________ Lloyd-Jones et al. Lancet 1999; 353:89-92 ____________________________________________________________ First Coronary Events: Framingham Study Study ________________________________________________________ Percent as Specified Event Percent Myocardial Infarction Age Men Women Angina Pectoris Men Women 35-64 43% 28% 65-84 55% 44% 41% 28% 59% 41% Sudden Death Death Men Women 9% 4% 11% 7.4% ____________________________________________________________ Framingham Study 44 year follow-up. Estimated 10-Year CHD Risk in 55-Year-Old Adults According to Levels of Various Risk Factors Framingham Heart Study A B C D Blood Pressure (mm Hg) 120/80 140/90 140/90 140/90 Total Cholesterol (mg/dL) 200 240 240 240 HDL Cholesterol (mg/dL) 50 50 40 40 Diabetes No No Yes Yes Cigarettes No No No Yes mm Hg = millimeters of mercury mg/dL = milligrams per deciliter of blood Source: Circulation 1998;97:1837-1847. Estimated 10-Year Rate (%) Estimated 10-Year Stroke Risk in 55Year-Old Adults According to Levels of Various Risk Factors Framingham Heart Study 30 27 25 22.4 19.1 20 14.8 15 8.4 10 5 2.6 5.4 4 3.5 2 1.1 6.3 0 A B C D Men Systolic BP* Diabetes Cigarettes Prior Atrial Fib. Prior CVD A 95-105 No No No No B 130-148 No No No No Source: Stroke 1991;22:312-318. E F Women C 130-148 Yes No No No D 130-148 Yes Yes No No E 130-148 Yes Yes Yes Yes No F 130-148 Yes Yes Yes Yes Yes *BP in millimeters of mercury (mmHg) Offspring CVD Risk by Parental CVD Status: Framingham Study Framingham Parental CVD <55 men, <65 Women NONE MATERNAL PATERNAL Risk Ratio 2.5 2.5 2 2 2.2 1.5 1.7 1.7 1.7 1 1 1.0 1.0 0.5 0 0 MEN Men WOMEN Women Adjusted for: age, total/HDL Chol. ratio, SBP, smoking, diabetes, BMI Risk imposed by a strong family history of heart attacks varies widely depending on the burden of modifiable risk factors Multivariable Risk 9 Doubts about cholesterol as late as 1989 _______________________________________________________________________________ Lifetime Risk of CHD Increases with Serum Cholesterol Cholesterol ___________________________________________________________________________ 60 50 57 Percent 40 30 Cholesterol <200 mg 200-239 mg >240 mg 44 34 29 20 19 10 0 33 Men Women Framingham Study: Subjects age 40 years DM Lloyd-Jones et al Arch Intern Med 2003; 1966-1972 Correlation Between Serum Cholesterol and CVD Mortality Cholesterol 6-Year CVD Death Rate Per 1000 30 Multiple Risk Factor Intervention Trial (MRFIT) N=325,346 Untreated Patients 25 55-57 years 20 50-54 years 15 45-49 years 10 40-44 years 35-39 years 5 0 Q1 (<182) Q2 (182-202) Q3 (203-220) Q4 (221-244) Q5 (>244) Serum Cholesterol Quintile (mg/dL) Q = serum cholesterol quintile. Kannel WB et al. Am Heart J. 1986;112:825-836. Mean Serum Total C holesterol 208 206 204 202 206 204 205 204 202 202 201 199 200 197 198 196 194 192 NH White NH Black 1988-94 1999-02 Mexican American 2003-04 Trends in mean total serum cholesterol among adults age 20 and older, by race/ethnicity, sex and survey age (NHANES : 1988-94, 1999-02 and 2003-04). (NHANES Source: NCHS and NHLBI. NH – non-Hispanic. Source: Percent of Population 45 40 35 30 25 20 15 10 5 0 39.0 32.0 32.0 32.0 34.0 32.0 30.0 31.0 Total Population NH Whites NH Blacks Mexican Americans Men Women Age-adjusted prevalence of Adults age 20 and older with LDL cholesterol of 130 mg/dL or higher, by race/ethnicity and sex (NHANES: 2003-2004). Source: NCHS and NHLBI. NH – non-Hispanic. Percent of Population 30 25 20 25 28 26 16 13 15 10 5 9 9 7 0 Total NH Whites Men NH Blacks Mexican Americans Women Age-adjusted prevalence of Adults age 20 and older with HDL cholesterol <40 mg/dL, by race/ethnicity and sex (NHANES: 2003-2004). Source: NCHS and NHLBI. NH – non-Hispanic. ________________________________________________________ CK Friedberg on Hypertension: Diseases of the Heart 1996 Diseases ___________________________________________________________ “There is a lack of correlation in There most cases between the severity and duration of hypertension and hypertension development of cardiac complications.” complications.” ______________________________________________________________ _ Relation of Non-Hypertensive Blood Pressure to Cardiovascular Disease to Vasan R, et al. N Engl J Med 2001; 345:1291-1297 10-year Age- Adjusted Cumulative Incidence 12% Hazard Ratio* <120/80 mm Hg 120-129/80-84 mm Hg 130-139/85-89 mm Hg 10% 10.1 8% 7.6 6% 5.8 4% 2% 0% SBP <120/80 120-129 130-139 1.0 1.5 2.5 1.0 1.3 1.6 H.R. adjusted for age, BMI, Cholesterol, Diabetes and smoking *P<.001 4.4 2.8 1.9 Women Women Men Men Framingham Study: Subjects Ages 35-90 yrs. Percent of Populati on 90 80 70 60 50 40 30 20 10 0 64.7 69.6 76.4 64.1 53.7 55.8 36.2 35.9 23.2 13.4 16.5 6.2 20-34 35-44 45-54 Men 55-64 65-74 75+ Women Prevalence of high blood pressure in Adults by age and sex (NHANES: 2005-2006). Source: NCHS and NHLBI. Source: (NHANES: Percent of Popul ati on Wi th Hypertensi on 90 80 70 60 50 40 30 20 10 0 78.8 79.0 82.3 67.6 74.7 69.1 70.1 52.1 46.5 45.4 46.1 35.2 Awareness Total Population NH Whites Treatment NH Blacks Controlled Mexican Americans Extent of awareness, treatment and control of high blood pressure by race/ethnicity (NHANES : 2005-2006). Source: NCHS and NHLBI. Source: Treatment (%) of HTN in US Adults, by Disease Status (Wong et al., Arch Intern Med 2007) (Wong Treatment of HTN (%) 100 80 ** 89 ** 84 66.5 68 70.9 ** 89.3 ** 83.4 73.4 65.9 60 40 20 0 No-Disease Dyslipidemia Mets DM *P<0.05, **P<0.01 when compared to No-Disease group Treatment is in persons with HTN CKD Stroke CHF PAD CAD Control (all treated) (%) of HTN in US Adults, by Disease Status (Wong et al., Arch Intern Med 2007) Arch Control of HTN (%) 100 80 60 64.6 * 49.3 63.7 61.2 48.8 ** 42.2 40 ** 34.9 ** 46.7 50.3 20 0 No-Disease Dyslipidemia Mets DM CKD Stroke **P<0.05**P<0.01 when compared to No-Disease Group Control is in persons with HTN defined as BP < 140/90 If DM and CKD is based on BP<130/80 control is **35.3% and **23.2%, respectively. If MetS is based on BP<130/85 control is **46.7% CHF PAD CAD ______________________________________________________________ _ CK Friedberg on Hypertension CK ______________________________________________________________ Diseases of the Heart 1966 _ “Hypertension imposes a load on Hypertension the heart which for many years may be compensated by left compensated ventricular hypertrophy” ventricular ______________________________________________________________ _ CVD Risk Imposed by ECG-LVH Framingham Study 36-yr. Follow-up Framingham _______________________________________________________________ Age-adjusted Rate per 1000 Rate Age Men Women 35-64 164 135 35-64 65-94 234 235 Risk Ratio Ratio Men Women 4.7*** 7.4*** 2.8*** 4.1*** Excess Risk per 1000 per Men Women 129 117 51 178 _____________________________________________________________ Biennial Rate per 1000. CVD=CHD, stroke, Biennial peripheral vascular disease, heart failure peripheral ***P<0.001 ___________________________________________________________ _ Smoking Statement Issued in 1956 by American Heart Association American ___________________________________________________________ “It is the belief of the committee that much It greater knowledge is needed before greater any conclusions can be drawn concerning relationships between smoking and death rates from coronary heart disease. The acquisition of such knowledge may well require the use of techniques and research methods that have not hitherto been applied to this __________________________________________________________ _ problem.” problem.” CHD Risk by Cigarette Smoking. Filter Vs. Non-filter. Framingham Study. Men Vs. <55 Yrs. <55 14-yr. Rate/1000 250 Non-Smoker Reg. Cig. Smoker Filter Cig. Smoker 200 206 210 150 100 50 0 210 119 112 59 Total CHD Myocardial Infarction Percent of Population 40 36.7 36.0 35 30 25 20 23.1 24.8 18.0 19.8 15.9 15.8 15 8.3 10 4.0 5 0 Men NH White Hispanic NH American Indian/Alaska Native Women NH Black NH Asian Prevalence of current smoking for Adults age 18 and older by race/ethnicity and sex (NHIS:2007). by Source: MMWR. 2008;57:1221-26. NH – non-Hispanic. Percent of Population 35 30 25 23.8 22.5 18.7 20 14.9 15 14.6 8.4 10 5 0 NH Whites NH Blacks Males Hispanics Females Prevalence of students in grades 9-12 reporting current cigarette smoking by race/ethnicity and sex. (YRBS:2007). Source: MMWR. 2008;57:SS04. NH – non-Hispanic. 2008;57:SS04. Diseases of The Heart Diseases Charles K Friedberg MD, WB Charles ________________________________________________________________ Saunders Co. Philadelphia, 1949 Saunders “The proper control of diabetes is The obviously desirable even though there is uncertainty as to whether coronary atherosclerosis is more frequent or severe in the uncontrolled diabetic” ______________________________________________________________ Risk of Cardiovascular Events in Diabetics Diabetics Framingham Study Framingham ________________________________________________________________ _ Age-adjusted Age-adjusted Cardiovascular Event Coronary Disease Stroke Peripheral Artery Dis. Cardiac Failure All CVD Events Biennial Rate Biennial Per 1000 Per Men Women Men 39 21 39 15 6 18 18 23 21 76 65 Age-adjusted Risk Ratio Risk Men Women Men 1.5** 2.2*** 2.9*** 2.6*** 3.4*** 6.4*** 4.4*** 7.8*** 2.2*** 3.7*** ________________________________________________________________ Subjects 35-64 36-year Follow-up **P<.001,***P<.0001 _ 14.9 Pe rcent of Population 16 14.2 13.1 14 11.3 12 10 8 6 6.1 5.8 4 2 0 Men NH Whites Women NH Blacks Mexican Americans Prevalence of physician-diagnosed diabetes in Adults age 20 and older by race/ethnicity and sex (NHANES: 2005-2006). Source: NCHS and NHLBI. NH – non-Hispanic. Source: 20 17.5 Percent of Population 18 15.3 16 14 13.0 12 10 8 6 4 10.8 12.2 12.0 8.1 6.1 5.4 2 0 NH Whites Less than high school NH Blacks High school Mexican Americans More than high school Prevalence of Physician Diagnosed Type 2 diabetes in Adults age 20+ by Race/Ethnicity, and Years of Education. (NHANES: age 2005-2006). Source: NCHS and NHLBI. NH – non-Hispanic. Source: Percent of Populat ion 10 7.4 8 6 8.0 5.4 5.4 3.8 3.4 4 2.5 2.1 2 0 Physician diagnosed 1988-94 Undiagnosed 1988-94 Male Physician diagnosed 2005-06 Undiagnosed 2005-06 Female Trends in diabetes prevalence in adults age 20+ by Sex Trends (NHANES: 1988-94 and 2005-2006). Source: NCHS and NHLBI. Source: NH – non-Hispanic. NH 50.0 44.1 Deaths/1000 Person Years 45.0 40.0 35.0 28.1 30.0 25.0 26.1 21.1 20.0 17.0 15.0 16.7 10.9 10.0 5.0 30.0 2.6 4.3 4.8 6.3 5.3 7.8 11.5 8.6 17.1 14.4 No MetS or DM MetS w/o DM MetS w/DM DM only Prior CVD Prior CVD and DM 0.0 CHD Mortality CVD Mortality Total Mortality Mortality rates in U.S. adults, age 30-75, with metabolic syndrome (MetS), with and without diabetes mellitus (DM) and pre-existing CVD (NHANES II: 1976-80 Follow-up Study). ** CVD Source: Malik et al., Circulation. 2004;110:1245-50. ** Average of 13 years of follow-up. Note: Age and gender adjusted. ** Skepticism About Importance of Obesity Skepticism Keys A, Aravanis C, Blackburn H, et al. Ann Intern Med 1972; 77:15-27. Concluded that all the excess risk of coronary heart disease in the obese derives from its atherogenic accompaniments, illogically leaving the impression that obesity is therefore unimportant. Mann GV. N Engl J Med 1974; 291:226-232. “The contribution of obesity to CHD is either small or non-existent. It cannot be expected that treating obesity is either logical or a promising approach to the management of CHD”. Barrett-Connor EL. Ann Intern Med 1985; 103:1010-1019 NIH consensus panel is equivocal about the role of obesity as a cause of CHD. Relation of Weight Change to Changes in Atherogenic Traits: The Framingham Study Frantz Ashley, Jr. and William B Kannel J Chronic Dis 1974 “Weight gain is accompanied by atherogenic alterations in blood lipids, blood pressure, uric acid and carbohydrate tolerance.” “It seems reasonable to expect that correction of overweight will improve the coronary risk problem.” “Avoidance of overweight would seem a desirable goal in the general population if the appalling annual toll from disease is to be substantially reduced.” Risk Factor Sum and Obesity Framingham Study Risk Factor Sum 3 2.4 1.8 (1971-74) and (1989-93) (1989) (1971) Risk factors accumulate with weight gain 1.2 0.6 0 Q1 Thin Q2 Q3 Q4 Risk variables include bottom quintile for HDL-C and top quintiles for cholesterol, SBP, triglycerides and glucose Q5 Obese Overall Wilson PWF, & Kannel WB Nutr Clin Care 1999; 1:44-50 Percent of Population 40 34 30.2 30 26 20.6 20 10.7 12.2 15.7 12.8 17.1 16.8 10 0 Men 1960-62 Women 1971-74 1976-80 1988-94 2001-2004 Age-adjusted prevalence of obesity in Adults ages 20-74 by sex Age-adjusted and survey. (NHES, 1960-62; NHANES, 1971-74, 1976-80, 1988(NHES, 94 and 2001-2004). Source: Health, United States, 2007. NCHS. Source: 94 Note: Obesity is defined as a BMI of 30.0 or higher. Perce nt of Popula tion 24 21.4 20 16 15.7 16.6 17.9 18.3 12.8 12 8 4 0 Males NH Whites Females NH Blacks Hispanics Prevalence of overweight among students in grades 9-12 by race/ethnicity and sex (YRBS: 2007). Source: MMWR. 2008 57: No. SS-4. BMI 95th percentile or higher by age and sex of the CDC 2000 growth chart. NH – non-Hispanic. 2000 60 Percent of Population 50 52.3 50.6 46.0 49.6 45.3 40 41.9 42.0 40.3 36.1 36.3 40.5 43.1 45.7 46.6 41.2 31.4 30 20 10 0 NH White NH Black Men '01 Women '01 Hispanic Men '05 Other race Women '05 Prevalence of regular leisure-time physical activity among adults age 18 and older by race/ethnicity, and sex. (BRFSS: 2001 and 2005). Source: MMWR, 2007;56:No. 46. NH – non-Hispanic. Source: 42.1 45 Percent of Population 40 35.2 35 28.2 30 25 20 21.8 16.7 18.8 15 10 5 0 Male Female NH White NH Black Hispanic Prevalence of students in grades 9-12 who did not meet currently recommended moderate-to-vigorous physical activity during the past 7 days by race/ethnicity, and sex. (YRBS: 2007). Source: MSSE 2008;40:181-8. NH – non-Hispanic. Source: Risk Assessment Risk Count major risk factors • For patients with multiple (2+) risk For factors factors – Perform 10-year risk assessment • For patients with 0–1 risk factor – 10 year risk assessment not required – Most patients have 10-year risk <10% ATP III Assessment of CHD Risk ATP For persons without known CHD, other forms of For without atherosclerotic disease, or diabetes: atherosclerotic • Count the number of risk factors: – Cigarette smoking – Hypertension (BP ≥ 140/90 mmHg or on Hypertension 140/90 antihypertensive medication) antihypertensive – Low HDL cholesterol (<40 mg/dL)† – Family history of premature CHD x x CHD in male first degree relative <55 years CHD in female first degree relative <65 years – Age (men ≥ 45 years; women ≥ 55 years) Age 45 • Use Framingham scoring for persons with ≥ 2 Use risk factors* (or with metabolic syndrome) to (or determine the absolute 10-year CHD risk. (downloadable risk algorithms at www.nhlbi.nih.gov) www.nhlbi.nih.gov) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497. © 2001, Professional Postgraduate Services® www.lipidhealth.org ATP III Framingham Risk Scoring Assessing CHD Risk in Men Step 1: Age Years Points 20-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 Step 4: Systolic Blood Pressure -9 -4 0 3 6 8 10 11 12 13 Systolic BP Points (mm Hg) Treated <120 120-129 130-139 140-159 ≥ 160 Step 6: Adding Up the Points Points if Untreated 0 0 1 1 2 Age if Total cholesterol 0 1 2 2 3 HDL-cholesterol Systolic blood pressure Step 7: CHD Risk Smoking status Point Total 10-Year Risk Point total Year Risk <0 <1% Step 2: Total Cholesterol 8% TC Points at Points at Points at Points at 0 1% Points at 10% (mg/dL) Age 20-39 Age 40-49 Age 50-59 Age 60-69 1 1% Age 70-79 12% <160 0 0 0 0 2 1% 0 16% 160-199 4 3 2 1 3 1% 0 20% 7 5 3 1 Step 200-239 3: HDL-Cholesterol 4 1% 0 HDL-C 25% 240-279 9 6 4 2 (mg/dL) Points Step 5: Smoking Status 5 2% 1 ≥ 60 ≥ 30% ≥ 280 11 -1 8 5 Points at 3 Points at Points at Points at 6 2% 1 50-59 0 Points at 7 Age 60-69 3% Age 20-39 Age 40-49 Age 50-59 40-49 1 8 4% Age 70-79 <40 2 9 5% Nonsmoker 0 0 0 0 Note: Risk estimates were derived from the experience of the Framingham Heart Study, 0 10 6% a predominantly Caucasian population in Massachusetts, USA. Smoker 8 5 3 1 1 Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497. Point Total 10- 11 12 13 14 15 16 ≥ 17 © 2001, Professional Postgraduate Services® www.lipidhealth.org ATP III Framingham Risk Scoring Assessing CHD Risk in Women Step 4: Systolic Blood Pressure Step 1: Age Systolic BP Points (mm Hg) Treated <120 120-129 130-139 140-159 ≥ 160 Years Points 20-34 -7 35-39 -3 40-44 0 45-49 3 50-54 6 55-59 8 60-64 10 65-69 12 70-74 14 Step 2: Total Cholesterol 75-79 16 TC Points at Points at (mg/dL) Age 20-39 Age 70-79 <160 0 0 160-199 4 1 8 Step 200-239 3: HDL-Cholesterol 1 HDL-C 240-279 11 (mg/dL) Points 2 ≥ 60 ≥ 280 13 -1 2 50-59 0 Step 6: Adding Up the Points Points if Untreated Age if 0 1 2 3 4 Points at Points at Points at Age 40-49 Age 50-59 Age 60-69 0 0 0 3 2 1 6 4 2 8 5 3 Step 5: Smoking Status 10 7 Points at 4 Points at Points at Age 20-39 Age 40-49 40-49 1 Age 70-79 <40 2 Nonsmoker 0 0 Note: Risk estimates were derived from the experience 0 the Framingham of a predominantly Caucasian population in Massachusetts, USA. Smoker 9 7 1 Total cholesterol 0 3 4 5 6 HDL-cholesterol Systolic blood pressure Step 7: CHD Risk Smoking status Point Total 10-Year Risk Point total Year Risk <9 <1% 11% 9 1% 14% 10 1% 17% 11 1% 22% 12 1% 27% 13 2% ≥ 30% 14 2% 15 Points at 3% Points at 16 4% Age 50-59 17 Age 60-69 5% 18 6% 0 0 19 8% Point Total 10- 20 21 22 23 24 ≥ 25 Heart Study, 4 Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497. 2 © 2001, Professional Postgraduate Services® www.lipidhealth.org ATP III Framingham Risk Scoring Step 1: Age Men Women Years Points 20-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 Years Points -9 -4 0 3 6 8 10 11 12 13 20-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 -7 -3 0 3 6 8 10 12 14 16 Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497. © 2001, Professional Postgraduate Services® www.lipidhealth.org ATP III Framingham Risk Scoring Step 2: Total Cholesterol Step Men TC Points at Points at Points at Points at (mg/dL) Age 20-39 Age 40-49 Age 50-59 Age 70-79 <160 0 0 0 0 160-199 4 3 2 0 200-239 7 5 3 0 Women 240-279 9 6 4 TC Points at Points at Points at 1 Points≥at 280 11 8 5 (mg/dL) Age 20-39 Age 40-49 Age 50-59 1 70-79 <160 0 0 0 0 160-199 4 3 2 1 Note: TC and HDL-C values should 8 the average of at 6 be least two fasting 4 200-239 lipoprotein measurements. 1 240-279 11 8 5 Expert Panel on Detection, Evaluation, and Treatment of High Blood 2 Cholesterol in Adults. JAMA. 2001;285:2486-2497. ≥ 280 13 10 7 Points at Age 60-69 0 1 1 2 Points at 3 Age 60-69 Age 0 1 2 3 © 2001, Professional Postgraduate Services® www.lipidhealth.org 4 ATP III Framingham Risk Scoring Step 3: HDL-Cholesterol Step Men HDL-C (mg/dL) Points ≥ 60 Women -1 HDL-C (mg/dL) Points ≥ 60 -1 50-59 0 50-59 0 40-49 1 40-49 1 <40 2 <40 2 Note: HDL-C and TC values should be the average of at least two fasting lipoprotein measurements. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497. © 2001, Professional Postgraduate Services® www.lipidhealth.org ATP III Framingham Risk Scoring Step 4: Systolic Blood Pressure Step Men Systolic BP (mm Hg) <120 120-129 130-139 140-159 ≥ 160 Points if Untreated 0 0 1 1 2 Points if Treated 0 1 2 2 3 Women Systolic BP Points Points (mm Hg) if Untreated if Treated <120 0 120-129 1 130-139 2 140-159 3 Note: The average of several BP measurements is needed for an accurate 4 measurement of baseline BP. If an ≥ 160 individual is on antihypertensive treatment, 0 3 4 5 6 extra points are added. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497. © 2001, Professional Postgraduate Services® www.lipidhealth.org ATP III Framingham Risk Scoring Step 5: Smoking Status Step Men Points at Points at Points at Points at Age 20-39 Age 40-49 Age 50-59 Age 60-69 0 0 0 0 8 5 3 1 Points at Points at Points at Points at Age 20-39 Age 40-49 Age 50-59 Age 60-69 0 0 0 0 9 7 4 2 Points at 70-79 Nonsmoker 0 Smoker Women 1 Age Points at 70-79 Nonsmoker 0 Smoker 1 Age Note: Any cigarette smoking in the past month. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497. © 2001, Professional Postgraduate Services® www.lipidhealth.org ATP III Framingham Risk Scoring Step 6: Adding Up the Points Step (Sum From Steps 1–5) Age Total cholesterol HDL-cholesterol Systolic blood pressure Smoking status Point total Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497. © 2001, Professional Postgraduate Services® www.lipidhealth.org ATP III Framingham Risk Scoring Step 7: CHD Risk for Men Step Point Total 10-Year Risk Point Total Risk <0 <1% 11 8% 0 1% 12 10% 1 1% 13 12% 2 1% 14 16% 3 1% 15 20% 4 1% 16 25% 5 ≥ 17 Note: Determine the 10-year absolute risk for2% CHD (MI and hard ≥ from point total. coronary death) 30% 6 2% Expert Panel on Detection, Evaluation, and Treatment of High Blood 3% Cholesterol in Adults. 7AMA. 2001;285:2486-2497. J 8 4% 10-Year © 2001, Professional Postgraduate Services® www.lipidhealth.org • Examination: Presentation Presentation – Height: 6 ft 2 in – Weight: 220 lb (BMI 28 Weight: kg/m2) kg/m – Waist circumference: 41 Waist in in – BP: 150/88 mm Hg – P: 64 bpm P: – RR: 12 breaths/min • Cardiopulmonary exam: normal normal • Laboratory results: – – – – – TC: 220 mg/dL HDL-C: 36 mg/dL LDL-C: 140 mg/dL TG: 220 mg/dL FBS: 120 mg/dL What is WJC’s 10-year absolute risk risk of fatal/nonfatal MI? • A 12% absolute risk is derived from points 12% assigned in Framingham Risk Scoring to: assigned – – – – – Age: 6 Age: TC: 3 TC: HDL-C: 2 HDL-C: SBP: 2 SBP: Total: 13 points In 1992 he exercised 14 minutes in a Bruce protocol exercise stress test to 91% of his maximum predicted heart rate without any abnormal ECG changes. He started on a statin in 2001. But in Sept 2004, he needed urgent coronary bypass surgery. ATP III Framingham Risk Scoring Step 7: CHD Risk for Women Step Point Total 10-Year Risk Point Total Risk <9 <1% 20 11% 9 1% 21 14% 10 1% 22 17% 11 1% 23 22% 12 1% 24 27% 13 2% ≥ 25 ≥ 30% 14 Note: Determine the 10-year absolute risk for2% CHD (MI and hard coronary death) from 15 total. point 3% 16 4% Expert Panel on Detection, Evaluation, and Treatment of High Blood 17 5% Cholesterol in Adults. JAMA. 2001;285:2486-2497. 18 6% 10-Year © 2001, Professional Postgraduate Services® www.lipidhealth.org CHD Risk Equivalents CHD • Risk for major coronary events Risk equal to that in established CHD equal • 10-year risk for hard CHD >20% Hard CHD = myocardial infarction + coronary death Diabetes as a CHD Risk Equivalent Equivalent • 10-year risk for CHD ≅ 20% 10-year • High mortality with established CHD – High mortality with acute MI – High mortality post acute MI CHD Risk Equivalents CHD • Other clinical forms of Other atherosclerotic disease (peripheral arterial disease, abdominal aortic aneurysm, and symptomatic carotid artery disease) artery • Diabetes • Multiple risk factors that confer a 10year risk for CHD >20% Framingham 10-year Total CVD Risk Algorithm (D’Agostino et al 2008) 2008) International Comparisons in CVD Morbidity and Mortality CVD • CVD accounts for 25-45% of deaths CVD among different countries among • CVD death rates (per 100,000) CVD range from 1310 in Russia to 201 in Japan (6.5 fold difference) in men and from 581 in Russia to 84 in France (7-fold difference) France • USA ranks 16th for both men (413) USA and women (201) and Secular Trends in CHD and Stroke Mortality Stroke • From 1985-1992, greatest annual From decline (6-7%) in CHD seen in Israel among men and France among women, USA intermediate (4%), increases in Poland and Romania. increases • Stroke death rates declined most in Stroke Australia, Italy, and France (8-9%), USA about 3%. USA Age-Adjusted Death Rates for Coronary Heart Disease by Country and Sex, Ages 35-74, 1999 •Age-Adjusted to European Standard •Data for 1999 unless noted Source: NHLBI 2002 Chart Book on Cardiovascular, Lung, and Blood Diseases Age-Adjusted Death Rates for Stroke by Country and Sex, Ages 35-74, 1999 •Age-Adjusted to European Standard •Data for 1999 unless noted Source: NHLBI 2002 Chart Book on Cardiovascular, Lung, and Blood Diseases Change in Age-Adjusted Death Rates for Coronary Heart Disease by Country and Sex, Ages 35-74, 1990-1999 Men Women •Age-Adjusted to European Standard •Latest data year note in parentheses Change in Age-Adjusted Death Rates for Stroke by Country and Sex, Ages 35-74, 1990-1999 Men Women •Age-Adjusted to European Standard •Latest data year note in parentheses Source: NHLBI 2002 Chart Book on Cardiovascular, Lung, and Blood Diseases Migrant Studies • Ni-Hon-San Study showed Ni-Hon-San Japanese living in Japan to have the lowest cholesterol levels and lowest rates of CHD, those living in Hawaii to have intermediate rates for both, and those living in San Francisco to have the highest cholesterol levels and CHD incidence incidence Pyramid of Risk (Werner et al. Canadian Journal of Cardiology 1998; 14(Suppl) B:3B-10B) 1998; Approaches to Primary and Secondary Prevention of CVD CVD • Primary prevention involves prevention Primary of onset of disease in persons without symptoms. symptoms. • Primordial prevention involves the Primordial prevention of risk factors causative o the disease, thereby reducing the likelihood of development of the disease. of • Secondary prevention refers to the Secondary prevention of death or recurrence of disease in those who are already symptomatic symptomatic Risk Factor Concepts in Primary Prevention Primary • Nonmodifiable risk factors include age, sexc, race, and family history of CVD, which can identify high-risk populations which • Behavioral risk factors include sedentary lifestyle, unhealthful diet, heavy alcohol or cigarette consumption. or • Physiological risk factors include hypertension, obesity, lipid problems, and diabetes, which may be a consequence of behavioral risk factors. consequence Population vs. High-Risk Approach Approach • Risk factors, such as cholesterol or blood Risk pressure, have a wide bell-shaped distribution, often with a “tail” of high values. often • The “high-risk approach” involves The identification and intensive treatment of those at the high end of the “tail”, often at greatest risk of CVD, reducing levels to “normal”. risk • But most cases of CVD do not occur among the But highest levels of a given risk factor, and in fact, occur among those in the “average” risk group. occur • Significant reduction in the population burden Significant of CVD can occur only from a “population approach” shifting the entire population distribution to lower levels. distribution Expected Shifts in Cholesterol Distribution from High-Risk, Population, and Combined Approaches Combined Population and CommunityPopulation Wide CVD Risk Reduction Wide Approaches Approaches • Populations with high rates of CVD are those with Populations Western lifestyles of high-fat diets, physical inactivity, and tobacco use. inactivity, • Targets of a population-wide approach must be Targets these behaviors causative of the physiologic risk factors or directly causative of CVD. factors • Requires public health services such as Requires surveillance (e.g.,BFRSS), education (AHA, NCEP), organizational partnerships (Singapore Declaration), and legislation/policy (Anti-Tobacco policies) policies) • Activities in a variety of community settings: Activities schools, worksites, churches, healthcare facilities, entire communities facilities, A conceptual framework for public health practice in CVD prevention. (From Pearson et al., J Public Health. 2001; 29:69 –78) Public 2001; Communitywide CVD Prevention Programs Prevention • Stanford 3-Community Study (1972-75) Stanford showed mass media vs. no intervention in high-risk residents to result in 23% reduction in CHD risk score in • North Karelia (1972-) showed public education North campaign to reduce smoking, fat consumption, blood pressure, and cholesterol consumption, • Stanford 5-City Project (1980-86) showed Stanford reductions in smoking, cholesterol, BP, and CHD risk CHD • Minnesota Heart Health Program (1980-88) Minnesota showed some increases in physical activity and in women reductions in smoking and Materials Developed for US Community Intervention Trials Trials • • • • • • • • • Mass media, brochures and direct mail Events and contests Screenings Group and direct education School programs and worksite School interventions interventions Physician and medical setting programs Grocery store and restaurant projects Church interventions Policies Individual and High-Risk Approaches Approaches • Primary Prevention Guidelines (1995) and Primary Secondary Prevention Guidelines (Revised 2001) released by the American Heart Association provide advice regarding risk factor assessment, lifestyle modification, and pharmacologic interventions for specific risk factors interventions • Barriers exist in the community and healthcare Barriers setting that prevent efficient risk reduction setting • Surveys of CVD prevention-related services show Surveys disappointing results regarding cholesteroldisappointing lowering therapy, smoking cessation, and other lowering measures of risk reduction measures ...
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This note was uploaded on 12/21/2011 for the course STEP 1 taught by Professor Dr.aslam during the Fall '11 term at Montgomery College.

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