Cardiovascular Epidemiology: Definitions Historical Perspectives and Assessing Risk of CVD Recent trends and population di...
A  Total CVD B  Cancer C  Accidents D  Chronic Lower Respiratory Diseases E  Diabetes Mellitus F  Alzheimer’s Disease CVD ...
Percent of Total Deaths  A  Total CVD B  Cancer C  Accidents D  Chronic Lower Respiratory Diseases E  Diabetes Mellitus F ...
Percentage breakdown of deaths from cardiovascular diseases  (United States: 2006 preliminary)    * - Not a true underlyin...
Age-adjusted death rates for CHD, stroke, lung and breast cancer for white and black females  (United States: 2005). Sourc...
CVD deaths vs. cancer deaths by age. (United States: 2005).  Source: NCHS and NHLBI.
Deaths from cardiovascular disease (United States: 1900–2006 preliminary).  Source: NCHS and NHLBI.
CVD disease  mortality  trends for males and females   (United States: 1979-2005).  S ource: NCHS and NHLBI.  Note:   No c...
Hospital discharges for cardiovascular diseases.  (United States: 1970-2006).  Note: Hospital discharges include people di...
Trends in Cardiovascular Operations and Procedures  (United States: 1979-2005) .  Source: NCHS and NHLBI. Note: Inpatient ...
Estimated direct and indirect costs (in billions of dollars) of major cardiovascular diseases and stroke  (United States: ...
Development of Atherosclerotic Plaques Normal Fatty streak Foam cells Lipid-rich plaque Lipid core Fibrous cap Thrombus Ro...
PDAY: Percentage of Right Coronary Artery Intimal Surface Affected With Early Atherosclerosis PDAY=   Pathobiological Dete...
Most Myocardial Infarctions Are Caused by Low-Grade Stenoses <ul><ul><li>Pooled data from 4 studies: Ambrose et al, 1988; ...
Coronary Remodeling (Adapted from Glagov et al.) Normal vessel Minimal CAD Progression Compensatory expansion maintains co...
Atherosclerotic Plaque Rupture and Thrombus Formation Intraluminal thrombus Growth of thrombus Intraplaque thrombus Lipid ...
Features of a Ruptured  Atherosclerotic Plaque <ul><li>Eccentric, lipid-rich </li></ul><ul><li>Fragile fibrous cap </li></...
Vulnerable Versus Stable  Atherosclerotic Plaques Libby P.  Circulation.  1995;91:2844-2850. Vulnerable Plaque <ul><li>Thi...
Correlation of CT angiography of the coronary arteries with intravascular ultrasound illustrates the ability of MDCT to de...
Clinical Manifestations  of Atherosclerosis <ul><ul><li>Coronary heart disease </li></ul></ul><ul><ul><ul><li>Stable angin...
Definitions <ul><li>CORONARY ARTERY DISEASE (CAD) or CORONARY HEART DISEASE (CHD) (often broadly referred to as ISCHEMIC H...
Definitions (cont.) <ul><li>SURROGATE MEASURES include: carotid intimal medial thickness (IMT), coronary calcium, angiogra...
Prevalence (%) of Coronary Calcium: US Adults Ages 45-84 Years  (The MESA Study). Source: Bild et al., Circulation. 2005;1...
Prevalence of stroke by age and sex  (NHANES: 2005-2006).  Source: NCHS and NHLBI.
Annual age-adjusted incidence of first-ever stroke, by race.  Inpatient plus out-of-hospital ascertainment.  (GCNKSS: 1993...
Prevalence of heart failure by age and sex  (NHANES: 2005-2006).  Source: NCHS and NHLBI.
Note: Hospital discharges include people discharged alive, dead and status unknown. Hospital discharges for heart failure ...
 
Lifetime Risk of Coronary Heart Disease in the Framingham Study <ul><li>Men  Women </li></ul>At age 40 years: 48.6% 31.7% ...
First Coronary Events: Framingham Study   <ul><li>Percent as Specified Event </li></ul><ul><li>Myocardial Angina   Sudden ...
Estimated 10-Year CHD Risk in  55-Year-Old Adults According to Levels  of Various Risk Factors Framingham Heart Study   A ...
Estimated 10-Year Stroke Risk in 55-Year-Old Adults According to Levels of Various Risk Factors  Framingham Heart Study A ...
Offspring CVD Risk by Parental CVD Status: Framingham Study Risk Ratio 2.5 2 1.5 1 0.5 0 Men Women 1.0 1.7 2.2 1.0 1.7 1.7...
Multivariable Risk Risk imposed by a strong family history of heart attacks varies widely depending on the burden of modif...
9 Doubts about  cholesterol as late as 1989
Lifetime Risk of CHD Increases with Serum Cholesterol Framingham Study: Subjects age 40 years DM Lloyd-Jones et al Arch In...
Correlation Between Serum  Cholesterol and CVD Mortality Q = serum cholesterol quintile. Kannel WB et al.  Am Heart J . 19...
Age-adjusted prevalence of Adults age 20 and older with LDL cholesterol of 130 mg/dL or higher, by race/ethnicity and sex ...
Age-adjusted prevalence of Adults age 20 and older with HDL cholesterol <40 mg/dL, by race/ethnicity and sex  (NHANES: 200...
Trends in mean total serum cholesterol among adults  age 20 and older, by race/ethnicity, sex and survey (NHANES : 1988-94...
 
CK Friedberg on Hypertension:  Diseases of the Heart 1996 <ul><li>“ There is a lack of correlation in most cases between t...
 
 
Relation of Non-Hypertensive Blood  Pressure to Cardiovascular Disease Vasan R, et al. N Engl J Med 2001; 345:1291-1297 10...
Prevalence of high blood pressure in Adults by age and sex  (NHANES: 2005-2006) .  Source: NCHS and NHLBI.
Extent of awareness, treatment and control of high blood pressure by race/ethnicity  (NHANES : 2005-2006).  Source: NCHS a...
Treatment (%) of HTN in US Adults, by Disease Status  (Wong et al., Arch Intern Med 2007) *P<0.05, **P <0.01 when compared...
Control (all treated) (%) of HTN in US Adults, by Disease Status (Wong et al., Arch Intern Med 2007) **P<0.05**P<0.01 when...
CK Friedberg on Hypertension Diseases of the Heart  1966 <ul><li>“ Hypertension imposes a load on the heart which for many...
CVD Risk Imposed by ECG-LVH Framingham Study 36-yr. Follow-up <ul><ul><ul><li>Age-adjusted   Risk   Excess Risk </li></ul>...
Smoking Statement Issued in 1956 by American Heart Association   <ul><li>“ It is the belief of the committee that much  gr...
CHD Risk by Cigarette Smoking. Filter Vs. Non-filter. Framingham Study .   Men <55 Yrs. 14-yr. Rate/1000  119 206 210 59 1...
Prevalence of current smoking for Adults age 18 and older by race/ethnicity and sex  (NHIS:2006). Source: MMWR. 2007;56:11...
Prevalence of students in grades 9-12 reporting current cigarette smoking by race/ethnicity and sex.  (YRBS:2007).  Source...
Diseases of The Heart Charles K Friedberg MD, WB Saunders Co. Philadelphia, 1949   <ul><li>“ The proper control of  diabet...
Risk of Cardiovascular Events in  Diabetics   Framingham Study <ul><li>  Age-adjusted </li></ul><ul><li>  Biennial Rate  A...
Prevalence of physician-diagnosed diabetes in Adults age 20 and older by race/ethnicity and sex  (NHANES: 2005-2006).  Sou...
Prevalence of Physician Diagnosed Type 2 diabetes in Adults age 20+ by Race/Ethnicity, and Years of Education.  (NHANES: 2...
Trends in diabetes prevalence in adults age 20+ by Sex  (NHANES: 1988-94 and 2005-2006).  Source: NCHS and NHLBI.  NH – no...
Mortality rates in U.S. adults,  age 30-75, with metabolic syndrome (MetS), with and without diabetes mellitus (DM) and pr...
 
Skepticism About Importance of Obesity Keys A , Aravanis C, Blackburn H, et al. Ann Intern Med 1972; 77:15-27. Concluded t...
Relation of Weight Change to Changes in  Atherogenic Traits: The Framingham Study Frantz Ashley, Jr. and William B Kannel ...
3 2.4 1.8 1.2 0.6 0 Q1 Q2 Q3 Q4 Q5 Overall Thin Obese Risk Factor Sum and Obesity (1971-74) and (1989-93) Risk Factor Sum ...
 
Note: Obesity is defined as a BMI of 30.0 or higher. Age-adjusted prevalence of obesity in Adults ages 20-74 by sex and su...
Prevalence of overweight among students in grades 9-12 by race/ethnicity and sex  (YRBS: 2007).  Source: MMWR. 2008 57: No...
 
Prevalence of regular leisure-time physical activity among adults age 18 and older by race/ethnicity, and sex.  (BRFSS: 20...
Prevalence of students in grades 9-12 who did not meet currently recommended moderate-to-vigorous physical activity during...
Risk Assessment <ul><li>Count major risk factors </li></ul><ul><li>For patients with multiple (2+) risk factors </li></ul>...
ATP III Assessment of CHD Risk <ul><li>For persons  without  known CHD, other forms of atherosclerotic disease, or diabete...
Assessing CHD Risk in Men Note: Risk estimates were derived from the experience of the Framingham Heart Study,  a predomin...
Assessing CHD Risk in Women Point Total 10-Year Risk Point Total 10-Year Risk <9 <1% 20 11% 9 1% 21 14% 10 1% 22 17% 11 1%...
Step 1: Age Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults.  JAMA . 2001;285:248...
Step 2: Total Cholesterol Note: TC and HDL-C values should be the average of at least two fasting  lipoprotein measurement...
Step 3: HDL-Cholesterol Note: HDL-C and TC values should be the average of at least two  fasting lipoprotein measurements....
Step 4: Systolic Blood Pressure Note: The average of several BP measurements is needed for an accurate measurement of base...
Step 5: Smoking Status Note: Any cigarette smoking in the past month. Expert Panel on Detection, Evaluation, and Treatment...
Step 6: Adding Up the Points (Sum From Steps 1–5) Expert Panel on Detection, Evaluation, and Treatment of High Blood Chole...
Step 7: CHD Risk for Men Note: Determine the 10-year absolute risk for hard CHD (MI and coronary death) from point total. ...
Presentation <ul><li>Examination: </li></ul><ul><ul><li>Height: 6 ft 2 in </li></ul></ul><ul><ul><li>Weight: 220 lb (BMI 2...
What is WJC’s 10-year absolute risk of fatal/nonfatal MI? <ul><li>A 12% absolute risk is derived from points assigned in F...
Step 7: CHD Risk for Women Note: Determine the 10-year absolute risk for hard CHD (MI and coronary death) from point total...
CHD Risk Equivalents <ul><li>Risk for major coronary events equal to that in established CHD </li></ul><ul><li>10-year ris...
Diabetes as a CHD Risk Equivalent <ul><li>10-year risk for CHD    20% </li></ul><ul><li>High mortality with established C...
CHD Risk Equivalents <ul><li>Other clinical forms of atherosclerotic disease (peripheral arterial disease, abdominal aorti...
International Comparisons in CVD Morbidity and Mortality <ul><li>CVD accounts for 25-45% of deaths among different countri...
Secular Trends in CHD and Stroke Mortality <ul><li>From 1985-1992, greatest annual decline (6-7%) in CHD seen in Israel am...
Age-Adjusted Death Rates for Coronary Heart Disease by Country and Sex, Ages 35-74, 1999 <ul><li>Age-Adjusted to European ...
Age-Adjusted Death Rates for Stroke by Country and Sex, Ages 35-74, 1999 <ul><li>Age-Adjusted to European Standard </li></...
Change in Age-Adjusted Death Rates for Coronary Heart Disease by Country and Sex, Ages 35-74, 1990-1999 <ul><li>Age-Adjust...
Change in Age-Adjusted Death Rates for Stroke  by Country and Sex, Ages 35-74, 1990-1999 <ul><li>Age-Adjusted to European ...
Migrant Studies  <ul><li>Ni-Hon-San Study showed Japanese living in Japan to have the lowest cholesterol levels and lowest...
Approaches to Primary and Secondary Prevention of CVD <ul><li>Primary prevention involves prevention of onset of disease i...
Risk Factor Concepts in Primary Prevention <ul><li>Nonmodifiable risk factors  include age, sexc, race, and family history...
Population vs. High-Risk Approach <ul><li>Risk factors, such as cholesterol or blood pressure, have a wide bell-shaped dis...
Pyramid of Risk  (Werner et al.  Canadian Journal of Cardiology  1998; 14(Suppl) B:3B-10B)
Expected Shifts in Cholesterol Distribution from High-Risk, Population, and Combined Approaches
Population and Community-Wide CVD Risk Reduction Approaches <ul><li>Populations with high rates of CVD are those with West...
A conceptual framework for public health practice in CVD prevention.    (From Pearson et al.,  J Public Health . 2001; 29:...
Communitywide CVD Prevention Programs <ul><li>Stanford 3-Community Study (1972-75) showed mass media vs. no intervention i...
Materials Developed for US Community Intervention Trials <ul><li>Mass media, brochures and direct mail </li></ul><ul><li>E...
Individual and High-Risk Approaches <ul><li>Primary Prevention Guidelines (1995) and Secondary Prevention Guidelines (Revi...
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CVD Definitions and Statistics

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  • 2.03
  • Rupture of atherosclerotic plaque and subsequent thrombosis of the vessel is responsible for the development of acute ischemic coronary syndromes. A lipid-rich core (particularly in the shoulder regions of lesions), abundance of inflammatory cells, a thin fibrous cap and dysfunctional overlying endothelium characterize plaques that are prone to rupture. Reference Weissberg PL. Eur Heart J Supplements 1999: 1 :T13–18.
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  • Hospital Specialty_FINAL ATS 08/26/10 10:47
  • CVD Definitions and Statistics

    1. 1. Cardiovascular Epidemiology: Definitions Historical Perspectives and Assessing Risk of CVD Recent trends and population differences in CHD and CHD risk factors
    2. 2. A Total CVD B Cancer C Accidents D Chronic Lower Respiratory Diseases E Diabetes Mellitus F Alzheimer’s Disease CVD and other major causes of death for all males and females (United States: 2005). Source: NCHS.
    3. 3. Percent of Total Deaths A Total CVD B Cancer C Accidents D Chronic Lower Respiratory Diseases E Diabetes Mellitus F Alzheimer’s Disease CVD and other major causes of death for white males and females (United States: 2005). Source: NCHS.
    4. 4. Percentage breakdown of deaths from cardiovascular diseases (United States: 2006 preliminary) * - Not a true underlying cause. Source: NCHS and NHLBI. Heart Failure*
    5. 5. Age-adjusted death rates for CHD, stroke, lung and breast cancer for white and black females (United States: 2005). Source: NCHS and NHLBI.
    6. 6. CVD deaths vs. cancer deaths by age. (United States: 2005). Source: NCHS and NHLBI.
    7. 7. Deaths from cardiovascular disease (United States: 1900–2006 preliminary). Source: NCHS and NHLBI.
    8. 8. CVD disease mortality trends for males and females (United States: 1979-2005). S ource: NCHS and NHLBI. Note: No comparability ratios were applied
    9. 9. Hospital discharges for cardiovascular diseases. (United States: 1970-2006). Note: Hospital discharges include people discharged alive, dead and status unknown. Source: NCHS and NHLBI.
    10. 10. Trends in Cardiovascular Operations and Procedures (United States: 1979-2005) . Source: NCHS and NHLBI. Note: Inpatient procedures only.
    11. 11. Estimated direct and indirect costs (in billions of dollars) of major cardiovascular diseases and stroke (United States: 2008). Source: NHLBI.
    12. 12. Development of Atherosclerotic Plaques Normal Fatty streak Foam cells Lipid-rich plaque Lipid core Fibrous cap Thrombus Ross R. Nature. 1993;362:801-809.
    13. 13. PDAY: Percentage of Right Coronary Artery Intimal Surface Affected With Early Atherosclerosis PDAY= Pathobiological Determinants of Atherosclerosis in Youth. Strong JP, et al. JAMA . 1999;281:727-735. Fatty streaks Raised lesions White 15-19 20-24 25-29 30-34 0 10 20 30 Women 0 10 20 30 15-19 20-24 25-29 30-34 Black Age (y) 0 10 20 30 White 15-19 20-24 25-29 30-34 Men Black Intimal surface (%) 15-19 20-24 25-29 30-34 0 10 20 30
    14. 14. Most Myocardial Infarctions Are Caused by Low-Grade Stenoses <ul><ul><li>Pooled data from 4 studies: Ambrose et al, 1988; Little et al, 1988; Nobuyoshi et al, 1991; and Giroud et al, 1992. (Adapted from Falk et al.) </li></ul></ul><ul><ul><li>Falk E et al, Circulation , 1995. </li></ul></ul>
    15. 15. Coronary Remodeling (Adapted from Glagov et al.) Normal vessel Minimal CAD Progression Compensatory expansion maintains constant lumen Expansion overcome: lumen narrows Severe CAD Moderate CAD Glagov et al, N Engl J Med , 1987.
    16. 16. Atherosclerotic Plaque Rupture and Thrombus Formation Intraluminal thrombus Growth of thrombus Intraplaque thrombus Lipid pool Blood Flow Adapted from Weissberg PL. Eur Heart J Supplements 1999:1:T13–18
    17. 17. Features of a Ruptured Atherosclerotic Plaque <ul><li>Eccentric, lipid-rich </li></ul><ul><li>Fragile fibrous cap </li></ul><ul><li>Prior luminal obstruction < 50% </li></ul><ul><li>Visible rupture and thrombus </li></ul>Constantinides P. Am J Cardiol. 1990;66:37G-40G.
    18. 18. Vulnerable Versus Stable Atherosclerotic Plaques Libby P. Circulation. 1995;91:2844-2850. Vulnerable Plaque <ul><li>Thin fibrous cap </li></ul><ul><li>Inflammatory cell infiltrates: </li></ul><ul><li>proteolytic activity </li></ul><ul><li>Lipid-rich plaque </li></ul>Lumen Lipid Core Fibrous Cap <ul><li>Thick fibrous cap </li></ul><ul><li>Smooth muscle cells: more extracellular matrix </li></ul><ul><li>Lipid-poor plaque </li></ul>Stable Plaque Lumen Lipid Core Fibrous Cap
    19. 19. 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)
    20. 20. Clinical Manifestations of Atherosclerosis <ul><ul><li>Coronary heart disease </li></ul></ul><ul><ul><ul><li>Stable angina, acute myocardial infarction, sudden death, unstable angina </li></ul></ul></ul><ul><ul><li>Cerebrovascular disease </li></ul></ul><ul><ul><ul><li>Stroke, TIAs </li></ul></ul></ul><ul><ul><li>Peripheral arterial disease </li></ul></ul><ul><ul><ul><li>Intermittent claudication, increased risk of death from heart attack and stroke </li></ul></ul></ul>American Heart Association, 2000.
    21. 21. Definitions <ul><li>CORONARY ARTERY DISEASE (CAD) or 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) </li></ul><ul><li>CARDIOVASCULAR DISEASE or CVD includes CHD, cerebrovascular disease, peripheral vascular disease, and other cardiac conditions (congenital, arrhythmias, and congestive heart failure) </li></ul>
    22. 22. Definitions (cont.) <ul><li>SURROGATE MEASURES include: carotid intimal medial thickness (IMT), coronary calcium, angiographic stenosis, brachial ultrasound flow mediated dilatation (FMD) </li></ul><ul><li>Hard endpoints include myocardial infarction, CHD death, and stroke </li></ul>
    23. 23. Prevalence (%) of Coronary Calcium: US Adults Ages 45-84 Years (The MESA Study). Source: Bild et al., Circulation. 2005;111:1313-1320.
    24. 24. Prevalence of stroke by age and sex (NHANES: 2005-2006). Source: NCHS and NHLBI.
    25. 25. 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.
    26. 26. Prevalence of heart failure by age and sex (NHANES: 2005-2006). Source: NCHS and NHLBI.
    27. 27. Note: Hospital discharges include people discharged alive, dead and status unknown. Hospital discharges for heart failure by sex. (United States: 1979-2006). Source: NHDS/NCHS and NHLBI.
    28. 29. Lifetime Risk of Coronary Heart Disease in the Framingham Study <ul><li>Men Women </li></ul>At age 40 years: 48.6% 31.7% At age 70 years: 34.9% 24.2% Lloyd-Jones et al. Lancet 1999; 353:89-92 ____________________________________________________________ ______________________________________________________________ _________________________________________________________________
    29. 30. First Coronary Events: Framingham Study <ul><li>Percent as Specified Event </li></ul><ul><li>Myocardial Angina Sudden </li></ul><ul><li>Infarction Pectoris Death </li></ul><ul><li>Age Men Women Men Women Men Women </li></ul><ul><li>35-64 43% 28% 41% 59% 9% 4% </li></ul><ul><li>65-84 55% 44% 28% 41% 11% 7.4% </li></ul><ul><li>Framingham Study 44 year follow-up. </li></ul>____________________________________________________________ ________________________________________________________ ____________________________________________________________
    30. 31. 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.
    31. 32. Estimated 10-Year Stroke Risk in 55-Year-Old Adults According to Levels of Various Risk Factors Framingham Heart Study A B C D E F Systolic BP* 95-105 130-148 130-148 130-148 130-148 130-148 Diabetes No No Yes Yes Yes Yes Cigarettes No No No Yes Yes Yes Prior Atrial Fib. No No No No Yes Yes Prior CVD No No No No No Yes Source: Stroke 1991;22:312-318. *BP in millimeters of mercury (mmHg)
    32. 33. Offspring CVD Risk by Parental CVD Status: Framingham Study Risk Ratio 2.5 2 1.5 1 0.5 0 Men Women 1.0 1.7 2.2 1.0 1.7 1.7 Adjusted for: age, total/HDL Chol. ratio, SBP, smoking, diabetes, BMI Parental CVD <55 men, <65 Women
    33. 34. Multivariable Risk Risk imposed by a strong family history of heart attacks varies widely depending on the burden of modifiable risk factors
    34. 35. 9 Doubts about cholesterol as late as 1989
    35. 36. Lifetime Risk of CHD Increases with Serum Cholesterol Framingham Study: Subjects age 40 years DM Lloyd-Jones et al Arch Intern Med 2003; 1966-1972 34 44 57 19 29 33 Cholesterol ___________________________________________________________________________ _______________________________________________________________________________
    36. 37. Correlation Between Serum Cholesterol and CVD Mortality Q = serum cholesterol quintile. Kannel WB et al. Am Heart J . 1986;112:825-836. Multiple Risk Factor Intervention Trial (MRFIT) N=325,346 6-Year CVD Death Rate Per 1000 0 5 10 15 20 25 30 Q 1 (<182) Q 2 (182-202 ) Q 3 (203-220) Q 4 (221-244) Q 5 (>244) 35-39 years 40-44 years 45-49 years 50-54 years 55-57 years Serum Cholesterol Quintile (mg/dL) Untreated Patients
    37. 38. 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.
    38. 39. 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.
    39. 40. Trends in mean total serum cholesterol among adults age 20 and older, by race/ethnicity, sex and survey (NHANES : 1988-94, 1999-02 and 2003-04). Source: NCHS and NHLBI. NH – non-Hispanic.
    40. 42. CK Friedberg on Hypertension: Diseases of the Heart 1996 <ul><li>“ There is a lack of correlation in most cases between the severity and duration of hypertension and development of cardiac complications.” </li></ul>___________________________________________________________ ________________________________________________________ _______________________________________________________________
    41. 45. Relation of Non-Hypertensive Blood Pressure to Cardiovascular Disease Vasan R, et al. N Engl J Med 2001; 345:1291-1297 10-year Age- Adjusted Cumulative Incidence Hazard Ratio* SBP Women Men <120/80 1.0 1.0 120-129 1.5 1.3 130-139 2.5 1.6 H.R. adjusted for age, BMI, Cholesterol, Diabetes and smoking *P<.001 Framingham Study: Subjects Ages 35-90 yrs. 1.9 2.8 4.4 5.8 7.6 10.1
    42. 46. Prevalence of high blood pressure in Adults by age and sex (NHANES: 2005-2006) . Source: NCHS and NHLBI.
    43. 47. Extent of awareness, treatment and control of high blood pressure by race/ethnicity (NHANES : 2005-2006). Source: NCHS and NHLBI.
    44. 48. Treatment (%) of HTN in US Adults, by Disease Status (Wong et al., Arch Intern Med 2007) *P<0.05, **P <0.01 when compared to No-Disease group Treatment is in persons with HTN ** ** ** **
    45. 49. Control (all treated) (%) of HTN in US Adults, by Disease Status (Wong et al., Arch Intern Med 2007) **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% * ** ** **
    46. 50. CK Friedberg on Hypertension Diseases of the Heart 1966 <ul><li>“ Hypertension imposes a load on the heart which for many years may be compensated by left ventricular hypertrophy” </li></ul>_______________________________________________________________ _______________________________________________________________
    47. 51. CVD Risk Imposed by ECG-LVH Framingham Study 36-yr. Follow-up <ul><ul><ul><li>Age-adjusted Risk Excess Risk </li></ul></ul></ul><ul><ul><ul><li>Rate per 1000 Ratio per 1000 </li></ul></ul></ul><ul><ul><ul><li>Age Men Women Men Women Men Women </li></ul></ul></ul><ul><ul><ul><li>35-64 164 135 4.7*** 7.4*** 129 117 </li></ul></ul></ul><ul><ul><ul><li>65-94 234 235 2.8*** 4.1*** 51 178 </li></ul></ul></ul><ul><ul><ul><li>Biennial Rate per 1000. CVD=CHD, stroke, peripheral vascular disease, heart failure ***P<0.001 </li></ul></ul></ul>_______________________________________________________________ _______________________________________________________________ _____________________________________________________________
    48. 52. Smoking Statement Issued in 1956 by American Heart Association <ul><li>“ It is the belief of the committee that much greater knowledge is needed before 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.” </li></ul><ul><li>Circulation 1960; vol. 23 </li></ul>___________________________________________________________ ____________________________________________________________ ___________________________________________________________
    49. 53. CHD Risk by Cigarette Smoking. Filter Vs. Non-filter. Framingham Study . Men <55 Yrs. 14-yr. Rate/1000 119 206 210 59 112 210
    50. 54. Prevalence of current smoking for Adults age 18 and older by race/ethnicity and sex (NHIS:2006). Source: MMWR. 2007;56:1157-61. NH – non-Hispanic.
    51. 55. 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.
    52. 56. Diseases of The Heart Charles K Friedberg MD, WB Saunders Co. Philadelphia, 1949 <ul><li>“ The proper control of diabetes is obviously desirable even though there is uncertainty as to whether coronary atherosclerosis is more frequent or severe in the uncontrolled diabetic” </li></ul>________________________________________________________________ ______________________________________________________________
    53. 57. Risk of Cardiovascular Events in Diabetics Framingham Study <ul><li> Age-adjusted </li></ul><ul><li> Biennial Rate Age-adjusted </li></ul><ul><li> Per 1000 Risk Ratio </li></ul><ul><li>Cardiovascular Event Men Women Men Women </li></ul><ul><li>Coronary Disease 39 21 1.5** 2.2*** </li></ul><ul><li>Stroke 15 6 2.9*** 2.6*** </li></ul><ul><li>Peripheral Artery Dis. 18 18 3.4*** 6.4*** </li></ul><ul><li>Cardiac Failure 23 21 4.4*** 7.8*** </li></ul><ul><li>All CVD Events 76 65 2.2*** 3.7*** </li></ul><ul><li>Subjects 35-64 36-year Follow-up **P<.001,***P<.0001 </li></ul>_________________________________________________________________ _________________________________________________________________
    54. 58. 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.
    55. 59. Prevalence of Physician Diagnosed Type 2 diabetes in Adults age 20+ by Race/Ethnicity, and Years of Education. (NHANES: 2005-2006). Source: NCHS and NHLBI. NH – non-Hispanic.
    56. 60. Trends in diabetes prevalence in adults age 20+ by Sex (NHANES: 1988-94 and 2005-2006). Source: NCHS and NHLBI. NH – non-Hispanic.
    57. 61. 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). ** Source: Malik et al., Circulation. 2004;110:1245-50. ** Average of 13 years of follow-up. Note: Age and gender adjusted.
    58. 63. Skepticism About Importance of Obesity 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.
    59. 64. 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.”
    60. 65. 3 2.4 1.8 1.2 0.6 0 Q1 Q2 Q3 Q4 Q5 Overall Thin Obese Risk Factor Sum and Obesity (1971-74) and (1989-93) Risk Factor Sum Risk variables include bottom quintile for HDL-C and top quintiles for cholesterol, SBP, triglycerides and glucose Wilson PWF, & Kannel WB Nutr Clin Care 1999; 1:44-50 Framingham Study Risk factors accumulate with weight gain (1971) (1989)
    61. 67. Note: Obesity is defined as a BMI of 30.0 or higher. Age-adjusted prevalence of obesity in Adults ages 20-74 by sex and survey. (NHES, 1960-62; NHANES, 1971-74, 1976-80, 1988-94 and 2001-2004). Source: Health, United States, 2007. NCHS .
    62. 68. 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.
    63. 70. 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.
    64. 71. 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.
    65. 72. Risk Assessment <ul><li>Count major risk factors </li></ul><ul><li>For patients with multiple (2+) risk factors </li></ul><ul><ul><li>Perform 10-year risk assessment </li></ul></ul><ul><li>For patients with 0–1 risk factor </li></ul><ul><ul><li>10 year risk assessment not required </li></ul></ul><ul><ul><li>Most patients have 10-year risk <10% </li></ul></ul>
    66. 73. ATP III Assessment of CHD Risk <ul><li>For persons without known CHD, other forms of atherosclerotic disease, or diabetes: </li></ul><ul><li>Count the number of risk factors: </li></ul><ul><ul><li>Cigarette smoking </li></ul></ul><ul><ul><li>Hypertension (BP  140/90 mmHg or on antihypertensive medication) </li></ul></ul><ul><ul><li>Low HDL cholesterol (<40 mg/dL) † </li></ul></ul><ul><ul><li>Family history of premature CHD </li></ul></ul><ul><ul><ul><li>CHD in male first degree relative <55 years </li></ul></ul></ul><ul><ul><ul><li>CHD in female first degree relative <65 years </li></ul></ul></ul><ul><ul><li>Age (men  45 years; women  55 years) </li></ul></ul><ul><li>Use Framingham scoring for persons with  2 risk factors* (or with metabolic syndrome) to determine the absolute 10-year CHD risk. (downloadable risk algorithms at www.nhlbi.nih.gov) </li></ul>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
    67. 74. Assessing CHD Risk in Men Note: Risk estimates were derived from the experience of the Framingham Heart Study, a predominantly Caucasian population in Massachusetts, USA. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA . 2001;285:2486-2497. Step 2: Total Cholesterol TC Points at Points at Points at Points at Points at (mg/dL) Age 20-39 Age 40-49 Age 50-59 Age 60-69 Age 70-79 <160 0 0 0 0 0 160-199 4 3 2 1 0 200-239 7 5 3 1 0 240-279 9 6 4 2 1  280 11 8 5 3 1 Point Total 10-Year Risk Point Total 10-Year 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 2%  17  30% 6 2% 7 3% 8 4% 9 5% 10 6% Step 7: CHD Risk ATP III Framingham Risk Scoring © 2001, Professional Postgraduate Services ® www.lipidhealth.org Step 1: Age Years Points 20-34 -9 35-39 -4 40-44 0 45-49 3 50-54 6 55-59 8 60-64 10 65-69 11 70-74 12 75-79 13 HDL-C (mg/dL) Points  60 -1 50-59 0 40-49 1 <40 2 Step 3: HDL-Cholesterol Systolic BP Points Points (mm Hg) if Untreated if Treated <120 0 0 120-129 0 1 130-139 1 2 140-159 1 2  160 2 3 Step 4: Systolic Blood Pressure Step 5: Smoking Status Points at Points at Points at Points at Points at Age 20-39 Age 40-49 Age 50-59 Age 60-69 Age 70-79 Nonsmoker 0 0 0 0 0 Smoker 8 5 3 1 1 Age Total cholesterol HDL-cholesterol Systolic blood pressure Smoking status Point total Step 6: Adding Up the Points
    68. 75. Assessing CHD Risk in Women Point Total 10-Year Risk Point Total 10-Year 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 2% 15 3% 16 4% 17 5% 18 6% 19 8% Note: Risk estimates were derived from the experience of the Framingham Heart Study, a predominantly Caucasian population in Massachusetts, USA. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA . 2001;285:2486-2497. TC Points at Points at Points at Points at Points at (mg/dL) Age 20-39 Age 40-49 Age 50-59 Age 60-69 Age 70-79 <160 0 0 0 0 0 160-199 4 3 2 1 1 200-239 8 6 4 2 1 240-279 11 8 5 3 2  280 13 10 7 4 2 Step 7: CHD Risk Step 2: Total Cholesterol ATP III Framingham Risk Scoring © 2001, Professional Postgraduate Services ® www.lipidhealth.org Step 1: Age 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 75-79 16 HDL-C (mg/dL) Points  60 -1 50-59 0 40-49 1 <40 2 Step 3: HDL-Cholesterol Systolic BP Points Points (mm Hg) if Untreated if Treated <120 0 0 120-129 1 3 130-139 2 4 140-159 3 5  160 4 6 Step 4: Systolic Blood Pressure Step 5: Smoking Status Points at Points at Points at Points at Points at Age 20-39 Age 40-49 Age 50-59 Age 60-69 Age 70-79 Nonsmoker 0 0 0 0 0 Smoker 9 7 4 2 1 Age Total cholesterol HDL-cholesterol Systolic blood pressure Smoking status Point total Step 6: Adding Up the Points
    69. 76. Step 1: Age Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA . 2001;285:2486-2497. ATP III Framingham Risk Scoring © 2001, Professional Postgraduate Services ® www.lipidhealth.org Men Years Points 20-34 -9 35-39 -4 40-44 0 45-49 3 50-54 6 55-59 8 60-64 10 65-69 11 70-74 12 75-79 13 Women 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 75-79 16
    70. 77. Step 2: Total Cholesterol Note: TC and HDL-C 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. Men TC Points at Points at Points at Points at Points at (mg/dL) Age 20-39 Age 40-49 Age 50-59 Age 60-69 Age 70-79 <160 0 0 0 0 0 160-199 4 3 2 1 0 200-239 7 5 3 1 0 240-279 9 6 4 2 1  280 11 8 5 3 1 Women TC Points at Points at Points at Points at Points at (mg/dL) Age 20-39 Age 40-49 Age 50-59 Age 60-69 Age 70-79 <160 0 0 0 0 0 160-199 4 3 2 1 1 200-239 8 6 4 2 1 240-279 11 8 5 3 2  280 13 10 7 4 2 ATP III Framingham Risk Scoring © 2001, Professional Postgraduate Services ® www.lipidhealth.org
    71. 78. Step 3: HDL-Cholesterol 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. Men Women ATP III Framingham Risk Scoring © 2001, Professional Postgraduate Services ® www.lipidhealth.org HDL-C (mg/dL) Points  60 -1 50-59 0 40-49 1 <40 2 HDL-C (mg/dL) Points  60 -1 50-59 0 40-49 1 <40 2
    72. 79. Step 4: Systolic Blood Pressure Note: The average of several BP measurements is needed for an accurate measurement of baseline BP. If an individual is on antihypertensive treatment, extra points are added. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA . 2001;285:2486-2497. ATP III Framingham Risk Scoring © 2001, Professional Postgraduate Services ® www.lipidhealth.org Men Systolic BP Points Points (mm Hg) if Untreated if Treated <120 0 0 120-129 0 1 130-139 1 2 140-159 1 2  160 2 3 Women Systolic BP Points Points (mm Hg) if Untreated if Treated <120 0 0 120-129 1 3 130-139 2 4 140-159 3 5  160 4 6
    73. 80. Step 5: Smoking Status 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. ATP III Framingham Risk Scoring © 2001, Professional Postgraduate Services ® www.lipidhealth.org Men Points at Points at Points at Points at Points at Age 20-39 Age 40-49 Age 50-59 Age 60-69 Age 70-79 Nonsmoker 0 0 0 0 0 Smoker 8 5 3 1 1 Women Points at Points at Points at Points at Points at Age 20-39 Age 40-49 Age 50-59 Age 60-69 Age 70-79 Nonsmoker 0 0 0 0 0 Smoker 9 7 4 2 1
    74. 81. Step 6: Adding Up the Points (Sum From Steps 1–5) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA . 2001;285:2486-2497. ATP III Framingham Risk Scoring © 2001, Professional Postgraduate Services ® www.lipidhealth.org Age Total cholesterol HDL-cholesterol Systolic blood pressure Smoking status Point total
    75. 82. Step 7: CHD Risk for Men Note: Determine the 10-year absolute risk for hard CHD (MI and coronary death) from point total. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA . 2001;285:2486-2497. ATP III Framingham Risk Scoring © 2001, Professional Postgraduate Services ® www.lipidhealth.org Point Total 10-Year Risk Point Total 10-Year 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 2%  17  30% 6 2% 7 3% 8 4% 9 5% 10 6%
    76. 83. Presentation <ul><li>Examination: </li></ul><ul><ul><li>Height: 6 ft 2 in </li></ul></ul><ul><ul><li>Weight: 220 lb (BMI 28 kg/m 2 ) </li></ul></ul><ul><ul><li>Waist circumference: 41 in </li></ul></ul><ul><ul><li>BP: 150/88 mm Hg </li></ul></ul><ul><ul><li>P: 64 bpm </li></ul></ul><ul><ul><li>RR: 12 breaths/min </li></ul></ul><ul><li>Cardiopulmonary exam: normal </li></ul><ul><li>Laboratory results: </li></ul><ul><ul><li>TC: 220 mg/dL </li></ul></ul><ul><ul><li>HDL-C: 36 mg/dL </li></ul></ul><ul><ul><li>LDL-C: 140 mg/dL </li></ul></ul><ul><ul><li>TG: 220 mg/dL </li></ul></ul><ul><ul><li>FBS: 120 mg/dL </li></ul></ul>
    77. 84. What is WJC’s 10-year absolute risk of fatal/nonfatal MI? <ul><li>A 12% absolute risk is derived from points assigned in Framingham Risk Scoring to: </li></ul><ul><ul><li>Age: 6 </li></ul></ul><ul><ul><li>TC: 3 </li></ul></ul><ul><ul><li>HDL-C: 2 </li></ul></ul><ul><ul><li>SBP: 2 </li></ul></ul><ul><ul><li>Total: 13 points </li></ul></ul>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 .
    78. 85. Step 7: CHD Risk for Women Note: Determine the 10-year absolute risk for hard CHD (MI and coronary death) from point total. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA . 2001;285:2486-2497. ATP III Framingham Risk Scoring © 2001, Professional Postgraduate Services ® www.lipidhealth.org Point Total 10-Year Risk Point Total 10-Year 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 2% 15 3% 16 4% 17 5% 18 6% 19 8%
    79. 86. CHD Risk Equivalents <ul><li>Risk for major coronary events equal to that in established CHD </li></ul><ul><li>10-year risk for hard CHD >20% </li></ul>Hard CHD = myocardial infarction + coronary death
    80. 87. Diabetes as a CHD Risk Equivalent <ul><li>10-year risk for CHD  20% </li></ul><ul><li>High mortality with established CHD </li></ul><ul><ul><li>High mortality with acute MI </li></ul></ul><ul><ul><li>High mortality post acute MI </li></ul></ul>
    81. 88. CHD Risk Equivalents <ul><li>Other clinical forms of atherosclerotic disease (peripheral arterial disease, abdominal aortic aneurysm, and symptomatic carotid artery disease) </li></ul><ul><li>Diabetes </li></ul><ul><li>Multiple risk factors that confer a 10-year risk for CHD >20% </li></ul>
    82. 89. International Comparisons in CVD Morbidity and Mortality <ul><li>CVD accounts for 25-45% of deaths among different countries </li></ul><ul><li>CVD death rates (per 100,000) 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) </li></ul><ul><li>USA ranks 16th for both men (413) and women (201) </li></ul>
    83. 90. Secular Trends in CHD and Stroke Mortality <ul><li>From 1985-1992, greatest annual decline (6-7%) in CHD seen in Israel among men and France among women, USA intermediate (4%), increases in Poland and Romania. </li></ul><ul><li>Stroke death rates declined most in Australia, Italy, and France (8-9%), USA about 3%. </li></ul>
    84. 91. Age-Adjusted Death Rates for Coronary Heart Disease by Country and Sex, Ages 35-74, 1999 <ul><li>Age-Adjusted to European Standard </li></ul><ul><li>Data for 1999 unless noted </li></ul><ul><li>Source: NHLBI 2002 Chart Book on Cardiovascular, Lung, and Blood Diseases </li></ul>
    85. 92. Age-Adjusted Death Rates for Stroke by Country and Sex, Ages 35-74, 1999 <ul><li>Age-Adjusted to European Standard </li></ul><ul><li>Data for 1999 unless noted </li></ul><ul><li>Source: NHLBI 2002 Chart Book on Cardiovascular, Lung, and Blood Diseases </li></ul>
    86. 93. Change in Age-Adjusted Death Rates for Coronary Heart Disease by Country and Sex, Ages 35-74, 1990-1999 <ul><li>Age-Adjusted to European Standard </li></ul><ul><li>Latest data year note in parentheses </li></ul><ul><li>Source: NHLBI 2002 Chart Book on Cardiovascular, Lung, and Blood Diseases </li></ul>Men Women
    87. 94. Change in Age-Adjusted Death Rates for Stroke by Country and Sex, Ages 35-74, 1990-1999 <ul><li>Age-Adjusted to European Standard </li></ul><ul><li>Latest data year note in parentheses </li></ul><ul><li>Source: NHLBI 2002 Chart Book on Cardiovascular, Lung, and Blood Diseases </li></ul>Men Women
    88. 95. Migrant Studies <ul><li>Ni-Hon-San Study showed 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 </li></ul>
    89. 96. Approaches to Primary and Secondary Prevention of CVD <ul><li>Primary prevention involves prevention of onset of disease in persons without symptoms. </li></ul><ul><li>Primordial prevention involves the prevention of risk factors causative o the disease, thereby reducing the likelihood of development of the disease. </li></ul><ul><li>Secondary prevention refers to the prevention of death or recurrence of disease in those who are already symptomatic </li></ul>
    90. 97. Risk Factor Concepts in Primary Prevention <ul><li>Nonmodifiable risk factors include age, sexc, race, and family history of CVD, which can identify high-risk populations </li></ul><ul><li>Behavioral risk factors include sedentary lifestyle, unhealthful diet, heavy alcohol or cigarette consumption. </li></ul><ul><li>Physiological risk factors include hypertension, obesity, lipid problems, and diabetes, which may be a consequence of behavioral risk factors. </li></ul>
    91. 98. Population vs. High-Risk Approach <ul><li>Risk factors, such as cholesterol or blood pressure, have a wide bell-shaped distribution, often with a “tail” of high values. </li></ul><ul><li>The “high-risk approach” involves identification and intensive treatment of those at the high end of the “tail”, often at greatest risk of CVD, reducing levels to “normal”. </li></ul><ul><li>But most cases of CVD do not occur among the highest levels of a given risk factor, and in fact, occur among those in the “average” risk group. </li></ul><ul><li>Significant reduction in the population burden of CVD can occur only from a “population approach” shifting the entire population distribution to lower levels. </li></ul>
    92. 99. Pyramid of Risk (Werner et al. Canadian Journal of Cardiology 1998; 14(Suppl) B:3B-10B)
    93. 100. Expected Shifts in Cholesterol Distribution from High-Risk, Population, and Combined Approaches
    94. 101. Population and Community-Wide CVD Risk Reduction Approaches <ul><li>Populations with high rates of CVD are those with Western lifestyles of high-fat diets, physical inactivity, and tobacco use. </li></ul><ul><li>Targets of a population-wide approach must be these behaviors causative of the physiologic risk factors or directly causative of CVD. </li></ul><ul><li>Requires public health services such as surveillance (e.g.,BFRSS), education (AHA, NCEP), organizational partnerships (Singapore Declaration), and legislation/policy (Anti-Tobacco policies) </li></ul><ul><li>Activities in a variety of community settings: schools, worksites, churches, healthcare facilities, entire communities </li></ul>
    95. 102. A conceptual framework for public health practice in CVD prevention. (From Pearson et al., J Public Health . 2001; 29:69 –78)
    96. 103. Communitywide CVD Prevention Programs <ul><li>Stanford 3-Community Study (1972-75) showed mass media vs. no intervention in high-risk residents to result in 23% reduction in CHD risk score </li></ul><ul><li>North Karelia (1972-) showed public education campaign to reduce smoking, fat consumption, blood pressure, and cholesterol </li></ul><ul><li>Stanford 5-City Project (1980-86) showed reductions in smoking, cholesterol, BP, and CHD risk </li></ul><ul><li>Minnesota Heart Health Program (1980-88) showed some increases in physical activity and in women reductions in smoking </li></ul>
    97. 104. Materials Developed for US Community Intervention Trials <ul><li>Mass media, brochures and direct mail </li></ul><ul><li>Events and contests </li></ul><ul><li>Screenings </li></ul><ul><li>Group and direct education </li></ul><ul><li>School programs and worksite interventions </li></ul><ul><li>Physician and medical setting programs </li></ul><ul><li>Grocery store and restaurant projects </li></ul><ul><li>Church interventions </li></ul><ul><li>Policies </li></ul>
    98. 105. Individual and High-Risk Approaches <ul><li>Primary Prevention Guidelines (1995) and 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 </li></ul><ul><li>Barriers exist in the community and healthcare setting that prevent efficient risk reduction </li></ul><ul><li>Surveys of CVD prevention-related services show disappointing results regarding cholesterol-lowering therapy, smoking cessation, and other measures of risk reduction </li></ul>
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