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CVD Definitions and Statistics 2008

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  • 1. Cardiovascular Epidemiology: Definitions Historical Perspectives and Assessing Risk of CVD Recent trends and population differences in CHD and CHD risk factors
  • 2. Deaths in Thousands 500 461 410 400 300 285 265 Males 200 Females 100 70 59 64 35 47 38 0 A B C D E A B D F E A Total CVD D Chronic Lower Respiratory Diseases B Cancer E Diabetes Mellitus C Accidents F Alzheimer’s Disease Leading causes of death for all males and females (United States: 2004). Source: NCHS and NHLBI.
  • 3. 200 Per 100,000 Population 148.7 150 114.7 100 65.5 47.2 41.9 39.9 50 32.2 23.9 0 Coronary Heart Stroke Lung Cancer Breast Cancer Disease White Females Black Females Age-adjusted death rates for CHD, stroke, lung and breast for white and black females (United States: 2004). Source: NCHS and NHLBI.
  • 4. 52% 13% 17% .4% 4% 6% 7% .5% Coronary Heart Disease Stroke Heart Failure High Blood Pressure Diseases of the Arteries Defects Congenital Cardiovascular Rheumatic Fever/ Other Rheumatic Heart Disease Percentage breakdown of deaths from cardiovascular diseases (United States:2004) Source: NCHS and NHLBI.
  • 5. 180 156.4 160 Billions of Dollars 140 120 100 80 65.5 69.4 60 34.8 40 20 0 Heart Failure Stroke Hypertensive Coronary Disease Heart Disease Estimated direct and indirect costs (in billions of dollars) of major cardiovascular diseases and stroke (United States: 2008). Source: NHLBI.
  • 6. 1400 Procedures in Thousands 1200 1000 800 600 400 200 0 79 80 85 90 95 00 05 Years Catheterizations Open-Heart Bypass PCI Carotid Endarterectomy Pacemakers Trends in Cardiovascular Operations and Procedures (United States: 1979-2005). Source: NCHS and NHLBI. Note: Inpatient procedures only.
  • 7. 1,000 900 872 800 Deaths in Thousands 700 600 555 500 400 325 300 267 200 165 130 139 80 78 96 100 16 15 46 49 5 3 4 4 0 <25 25-34 35-44 45-54 55-64 65-74 75-84 85+ Total CVD Cancer Cardiovascular disease deaths vs. cancer deaths by age (United States: 2004). Source: NCHS and NHLBI.
  • 8. Development of Atherosclerotic Plaques Fatty streak Normal Lipid-rich plaque Foam cells Fibrous cap Lipid core Thrombus Ross R. Nature. 1993;362:801-809.
  • 9. Atherosclerotic Plaque Rupture and Thrombus Formation Growth of thrombus Intraluminal thrombus Blood Flow Intraplaque thrombus Lipid pool Adapted from Weissberg PL. Eur Heart J Supplements 1999:1:T13–18
  • 10. PDAY: Percentage of Right Coronary Artery Intimal Surface Affected With Early Atherosclerosis 30 Raised lesions 30 Men Fatty streaks Women 20 20 10 10 0 0 Intimal 15-19 20-24 25-29 30-34 15-19 20-24 25-29 30-34 surface 30 White White 30 (%) 20 20 10 10 0 0 15-19 20-24 25-29 30-34 15-1920-2425-2930-34 Black Black Age (y) PDAY= Pathobiological Determinants of Atherosclerosis in Youth. Strong JP, et al. JAMA. 1999;281:727-735.
  • 11. Coronary Remodeling Progression Expansion Compensatory expansion overcome: maintains constant lumen lumen narrows Normal Minimal Moderate Severe vessel CAD CAD CAD (Adapted from Glagov et al.) Glagov et al, N Engl J Med, 1987.
  • 12. Most Myocardial Infarctions Are Caused 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, 1992. (Adapted from Falk et al.) Falk E et al, Circulation, 1995.
  • 13. Vulnerable Versus Stable Atherosclerotic Plaques Vulnerable Plaque Lumen Lipid • Thin fibrous cap Fibrous Cap Core • Inflammatory cell infiltrates: proteolytic activity • Lipid-rich plaque Stable Plaque • Thick fibrous cap Lumen Lipid • Smooth muscle cells: Core more extracellular matrix Fibrous Cap • Lipid-poor plaque Libby P. Circulation. 1995;91:2844-2850.
  • 14. 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)
  • 15. 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.
  • 16. Clinical Manifestations of Atherosclerosis • Coronary heart disease – Stable angina, acute myocardial infarction, sudden death, unstable angina • Cerebrovascular disease – Stroke, TIAs • Peripheral arterial disease – Intermittent claudication, increased risk of death from heart attack and stroke American Heart Association, 2000.
  • 17. Definitions • CARDIOVASCULAR DISEASE or CVD includes CORONARY ARTERY DISEASE and other cardiac conditions (congenital, arrhythmias, and congestive heart failure) • 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, revascularization, and myocardial infarction
  • 18. Definitions (cont.) • REVASCULARIZATION includes coronary artery bypass graft (CABG), percutaneous transluminal coronary angioplasty (PTCA), stent, and atherectomy • CEREBROVASCULAR DISEASE includes stroke (ischemic or hemorrhagic) and transient ischemic attack (TIA) • PERIPHERAL VASCULAR DISEASE includes carotid artery disease and intermittent claudication • SURROGATE MEASURES include: carotid intimal medial thickness (IMT), coronary calcium, angiographic stenosis, brachial ultrasound flow mediated dilatation (FMD)
  • 19. 80 74.4 Per 1,000 Person Years 70 65.2 59.2 60 50 40.2 40 34.6 30 21.4 20.0 20 10.1 8.9 10 4.2 0 45-54 55-64 65-74 75-84 85-94 Age Men Women Incidence of CVD* by age and sex. FHS, 1980-2003. NHLBI. * Includes CHD, HF, stroke or intracerebral hemorrhage. Does not include hypertension alone.
  • 20. 550 Deaths in Thousands 500 450 400 79 80 85 90 95 00 04 Years Males Females
  • 21. Source: NHLBI 2002 Chart Book on Cardiovascular, Lung, and Blood Diseases
  • 22. 35.0 32.7 Percent of Population 30.0 25.0 22.8 21.6 20.0 15.4 15.0 10.0 7.8 5.5 5.0 0.6 0.6 0.0 20-39 40-59 60-79 80+ Men Women Prevalence of coronary heart disease by age and sex (NHANES :1999-2004). Source: NCHS and NHLBI.
  • 23. Discharges in Thousands 1400 1200 1000 800 600 400 200 0 70 75 80 85 90 95 00 05 Years Males Females Hospital discharges for coronary heart disease by sex (United States: 1970-2005). Source: NHDS/NCHS and NHLBI.
  • 24. New and Recurrent MI or 350000 290000 300000 265000 235000 250000 Fatal CHD 180000 200000 150000 95000 95000 100000 50000 30000 10000 0 35-44 45-64 65-74 75+ Ages Men Women Annual number of U.S. Adults having diagnosed heart attack by age and sex (ARIC: 1987-2004). Source: NHLBI. Includes MI and fatal CHD but not silent MI’s.
  • 25. 16 14 Per 1,000 Persons 12 10 8 6 4 2 0 35-44 45-54 55-64 65-74 White Men Black Men White Women Black Women Annual rate of first heart attack by age, sex and race. (ARIC :1987-2004). Source: NHLBI.
  • 26. 16 14.8 Percent of Population 14 12.4 12 10 8 6.5 6.2 6 4 2.3 2 1.2 0.5 0.5 0 20-39 40-59 60-79 80+ Men Women Prevalence of stroke by age and sex (NHANES: 1999-2004). Source: NCHS and NHLBI.
  • 27. 250 Incidence per 100,000 226 219 200 181 156 150 100 42 44 50 20 24 6 7 11 11 0 Ischemic Intracerebral Subarachnoid hemorrhage hemorrhage White '93-94 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.
  • 28. 14 12.4 11.6 Percent of Population 12 10 8 7.2 6 5.2 4 2 1.5 2 0.3 0.2 0 20-39 40-59 60-79 80+ Men Women Prevalence of heart failure by age and sex (NHANES: 1999-2004). Source: NCHS and NHLBI.
  • 29. 700 Discharges in Thousands 600 500 400 300 200 100 0 79 80 85 90 95 00 05 Years Male Female Hospital discharges for heart failure by sex (United States: 1979-2005). Source: NHDS, NCHS and NHLBI. Note: Hospital discharges include people discharged alive, dead and status unknown.
  • 30. ____________________________________________________________ Lifetime Risk of Coronary Heart Disease in the Framingham Study ______________________________________________________________ Men Women 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
  • 31. ____________________________________________________________ First Coronary Events: Framingham Study ________________________________________________________ Percent as Specified Event Myocardial Angina Sudden Infarction Pectoris Death Age Men Women Men Women Men Women 35-64 43% 28% 41% 59% 9% 4% 65-84 55% 44% 28% 41% 11% 7.4% ____________________________________________________________ Framingham Study 44 year follow-up.
  • 32. Estimated 10-Year CHD Risk in 55-Year-Old Adults According to Levels of Various Risk Factors Framingham Heart Study 40 37 Estimated 10-Year Rate (%) 35 30 25 27 25 20 Men 20 13 Women 15 8 10 5 5 5 0 A B C D 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.
  • 33. Estimated 10-Year Stroke Risk in 55- Year-Old Adults According to Levels of Various Risk Factors Framingham Heart Study 30 27 Estimated 10-Year Rate (%) 25 22.4 19.1 20 14.8 15 10 8.4 5.4 6.3 5 4 3.5 2.6 2 1.1 0 A B C D E F Men Women 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)
  • 34. Offspring CVD Risk by Parental CVD Status: Framingham Study Parental CVD <55 Risk Ratio men, <65 Women 2.5 2.5 NONE MATERNAL 2 2 PATERNAL 2.2 1.5 1.7 1.7 1.7 1 1 1.0 1.0 0.5 0.5 0 0 Men MEN Women WOMEN Adjusted for: age, total/HDL Chol. ratio, SBP, smoking, diabetes, BMI
  • 35. Risk imposed by a strong family history of heart attacks varies widely depending on the burden of modifiable risk factors Multivariable Risk
  • 36. 9 Doubts about cholesterol as late as 1989
  • 37. Risk of Coronary Heart Disease by Serum Cholesterol 30-Year Follow-up, The Framingham Study Age-Adjusted Annual Rate per 1000 Age: 35-64* Age: 65-94 Serum Wome Cholesterol Men n Men+ Women* 84-204 8 4 22 11 205-234 13 5 24 15 235-264 14 4 26 17 265-294 15 7 23 17 295-1124 26 10 38 32 *Trends Significant at P .001. +P .07.
  • 38. Correlation Between Serum Cholesterol and CVD Mortality Multiple Risk Factor Intervention Trial (MRFIT) 30 N=325,346 Untreated Patients 6-Year CVD Death Rate Per 1000 25 55-57 years 20 50-54 years 15 45-49 years 10 40-44 years 5 35-39 years 0 Q1 Q2 Q3 Q4 Q5 (<182) (182-202) (203-220) (221-244) (>244) Serum Cholesterol Quintile (mg/dL) Q = serum cholesterol quintile. Kannel WB et al. Am Heart J. 1986;112:825-836.
  • 39. _______________________________________________________________________________ Lifetime Risk of CHD Increases with Serum Cholesterol ___________________________________________________________________________ 60 Cholesterol 50 57 <200 mg 200-239 mg >240 mg 40 44 Percent 30 34 33 20 29 19 10 0 Men Women Framingham Study: Subjects age 40 years DM Lloyd-Jones et al Arch Intern Med 2003; 1966-1972
  • 40. 45 39.0 Percent of Population 40 34.0 35 32.0 32.0 32.0 32.0 30.0 31.0 30 25 20 15 10 5 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.
  • 41. Percent of Population 30 28 25 26 25 20 16 15 13 9 9 10 7 5 0 Total NH Whites NH Blacks Mexican Americans Men 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.
  • 42. Mean Serum Total Cholesterol 208 206 206 205 204 204 204 202 202 202 201 200 199 198 197 196 194 192 NH White NH Black Mexican American 1988-94 1999-02 2003-04 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.
  • 43. Mean Total Blood Cholesterol 180 174 175 172 171 170 170 168 165 166 166 165 163 163 163 164 161 161 160 155 156 155 150 145 White Males Black Males White Females Black Females 1976-80 1988-94 1999-02 2003-04 Trends in mean total blood cholesterol among adolescents ages 12-17 by race, sex, and survey (NHES: 1966-70; NHANES: 1971-74 and 1988-94). Source: NCHS and NHLBI.
  • 44. ________________________________________________________ CK Friedberg on Hypertension: ___________________________________________________________ Diseases of the Heart 1996 “There is a lack of correlation in most cases between the severity and duration of hypertension and development of cardiac complications.” _______________________________________________________________
  • 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 12% Hazard Ratio* <120/80 mm Hg 120-129/80-84 mm Hg SBP Women Men 10% 130-139/85-89 mm Hg 10.1 <120/80 1.0 1.0 8% 120-129 1.5 1.3 7.6 130-139 2.5 1.6 6% 5.8 H.R. adjusted for age, BMI, Cholesterol, Dia 4% 4.4 betes and smoking *P<.001 2.8 2% 1.9 0% Women Men Framingham Study: Subjects Ages 35-90 yrs.
  • 46. 90.0 83.8 80.0 73.9 Percent of Population 69.5 70.0 63.6 60.0 55.4 49.1 50.0 37.5 37.4 40.0 30.0 23.2 18.3 20.0 11.2 10.0 6.4 0.0 20-34 35-44 45-54 55-64 65-74 75+ Men Women Prevalence of high blood pressure in Adults by age and sex (NHANES: 1999-2004). Source: NCHS and NHLBI.
  • 47. 80 74.6 75.3 68.4 Percent of Population 70 62.5 60 52.3 50 39.8 40 35.8 34.3 30 24.6 20 10 0 Awareness Treatment Controlled 20-39 40-59 60+ Extent of awareness, treatment and control of high blood pressure by age (NHANES : 1999-2004.) Source: NCHS and NHLBI.
  • 48. 50 Percent of Population 37.5 39.0 38.2 41.4 40 28.5 28.0 26.9 26.2 27.0 30 25.6 25.0 22.9 20 10 0 NH White- NH White- NH Black NH Black Mexican Mexican Only Men Only or AA Men or AA Men Women Women Women 1988-94 1999-04 Age-adjusted prevalence trends for high blood pressure in Adults age 20 and older by race/ethnicity, sex and survey (NHANES: 1988-94 and 1999-2004). Source: NCHS and NHLBI.
  • 49. 90 Percent of Population 80 72.9 76.9 66.9 70 62.4 63.4 60 49.1 50 37.2 40 33.6 30 25.1 20 10 0 Awareness Treatment Controlled NH Whites NH Blacks Mexican Americans Extent of Awareness, Treatment and Control of High Blood Pressure by Race/Ethnicity (NHANES: 1999-2004). Source: NCHS and NHLBI.
  • 50. Treatment (%) of HTN in US Adults, by Disease Status (Wong et al., Arch Intern Med 2007) 100 ** ** ** 89 ** 89.3 84 83.4 Treatment of HTN (%) 80 73.4 66.5 68 70.9 65.9 60 40 20 0 No-Disease Dyslipidemia Mets DM CKD Stroke CHF PAD CAD *P<0.05, **P<0.01 when compared to No-Disease group Treatment is in persons with HTN
  • 51. Control (all treated) (%) of HTN in US Adults, by Disease Status (Wong et al., Arch Intern Med 2007) 100 Control of HTN (%) 80 64.6 63.7 61.2 60 * 49.3 48.8 ** ** 46.7 50.3 42.2 ** 34.9 40 20 0 No-Disease Dyslipidemia Mets DM CKD Stroke CHF PAD CAD **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%
  • 52. _______________________________________________________________ CK Friedberg on Hypertension _______________________________________________________________ Diseases of the Heart 1966 “Hypertension imposes a load on the heart which for many years may be compensated by left ventricular hypertrophy”
  • 53. _______________________________________________________________ CVD Risk Imposed by ECG-LVH Framingham Study 36-yr. Follow-up _______________________________________________________________ Age-adjusted Risk Excess Risk Rate per 1000 Ratio per 1000 Age Men Women Men Women Men Women 35-64 164 135 4.7*** 7.4*** 129 117 65-94 234 235 2.8*** 4.1*** 51 178 _____________________________________________________________ Biennial Rate per 1000. CVD=CHD, stroke, peripheral vascular disease, heart failure ***P<0.001
  • 54. ____________________________________________________________ Smoking Statement Issued in 1956 by American Heart Association ___________________________________________________________ “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.”
  • 55. CHD Risk by Cigarette Smoking. Filter Vs. Non-filter. Framingham Study. Men <55 Yrs. 14-yr. Rate/1000 250 Non-Smoker 200 Reg. Cig. Smoker 206 210 Filter Cig. Smoker 150 210 100 119 112 50 59 0 Total CHD Myocardial Infarction
  • 56. 37.5 40 Percent of Population 35 30 26.7 26.8 24.0 25 21.1 20.6 20.0 20 17.3 15 11.1 10 6.1 5 0 Men Women NH White NH Black Hispanic NH Asian NH American Indian/Alaska Native Prevalence of current smoking for Adults age 18 and older by race/ethnicity and sex (NHIS:2005). Source: MMWR. 2006;55:1145-48. NH – non-Hispanic.
  • 57. 45 Percent of Population 40 35 30 24.9 27 24.8 25 19.2 20 14 15 11.9 10 5 0 NH Whites NH Blacks Hispanics Males Females Prevalence of high school students in grades 9-12 reporting current cigarette smoking by race/ethnicity and sex. (YRBS:2005).Source: MMWR. 2006;55:SS-5. June 9, 2006. . NH – non-Hispanic.
  • 58. Diseases of The Heart Charles K Friedberg MD, WB Saunders Co. Philadelphia, 1949 ________________________________________________________________ “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” ______________________________________________________________
  • 59. Risk of Cardiovascular Events in Diabetics Framingham Study _________________________________________________________________ Age-adjusted Biennial Rate Age-adjusted Per 1000 Risk Ratio Cardiovascular Event Men Women Men Women Coronary Disease 39 21 1.5** 2.2*** Stroke 15 6 2.9*** 2.6*** Peripheral Artery Dis. 18 18 3.4*** 6.4*** Cardiac Failure 23 21 4.4*** 7.8*** All CVD Events 76 65 2.2*** 3.7*** _________________________________________________________________ Subjects 35-64 36-year Follow-up **P<.001,***P<.0001
  • 60. 14.0 13.2 12.0 11.0 10.9 10.7 Percent of Population 10.0 8.0 6.7 5.6 6.0 4.0 2.0 0.0 Men Women NH Whites NH Blacks Mexican Americans Age-adjusted prevalence of physician-diagnosed diabetes in Adults age 18 and older by race/ethnicity and sex (NHANES: 1999-2004). Source: NCHS and NHLBI. NH – non-Hispanic.
  • 61. 50.0 44.1 45.0 Deaths/1000 Person Years 40.0 35.0 No MetS or DM 30.0 30.0 28.1 MetS w/o DM 26.1 25.0 MetS w/DM 21.1 DM only 20.0 17.0 16.7 17.1 14.4 Prior CVD 15.0 10.9 11.5 8.6 Prior CVD and DM 10.0 6.3 7.8 4.3 4.8 5.3 5.0 2.6 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). ** Source: Malik et al., Circulation. 2004;110:1245-50. ** Average of 13 years of follow-up. Note: Age and gender adjusted.
  • 62. 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.
  • 63. 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.”
  • 64. Risk Factor Sum and Obesity Framingham Study 3 (1971-74) and (1989-93) 2.4 (1971) (1989) Risk Factor Sum Risk factors accumulate with weight gain 1.8 1.2 0.6 0 Q1 Q2 Q3 Q4 Q5 Overall Thin Obese 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
  • 65. 40 34 Percent of Population 30.2 30 26 20.6 20 16.8 17.1 15.7 10.7 12.2 12.8 10 0 Men Women 1960-62 1971-74 1976-80 1988-94 2001-2004 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, 2006, unpublished data. NCHS. Note: Obesity is defined as a BMI of 30.0 or higher.
  • 66. 20 18.7 18 16.3 Percent of Population 16 14 11.6 11 12 10 8 6.6 6.4 6 4.3 3.6 4 2 0 6-11 12-19 1971-74 1976-80 1988-94 2001-2004 Trends in prevalence of overweight among U.S. children and adolescents by age and survey (NHANES, 1971-74, 1976-80, 1988-94 and 2001-2004). Source: Health, United States, 2006, unpublished data. NCHS.
  • 67. 24 21.3 Percent of Population 20 15.9 16.1 15.2 16 12.1 12 8.2 8 4 0 Males Females NH Whites NH Blacks Hispanics Prevalence of overweight among students in grades 9-12 by race/ethnicity and sex (YRBS: 2005). Source: BMI 95th percentile or higher. MMWR. 2006 55: No. SS-5. NH – non-Hispanic.
  • 68. 50 45.7 44.8 45 32.5 39.6 Percent of Population 40 37.5 36.3 34.2 34.4 31.8 35 27.0 33.9 31.5 23.8 28.3 30 26.4 25.0 20.4 24.0 25 18.4 21.6 20 15 10 5 0 NH White NH Black Hispanic Asian/Pac. Isl. Am. Ind./Al. Native Male '94 Female '94 Male '04 Female '04 Prevalence of leisure-time physical inactivity among adults age 18 and older by race/ethnicity, and sex. (BRFSS: 1994 and 2004). Source: MMWR, 2005;54:No. 39:991-994. NH – non-Hispanic.
  • 69. 50 46.9 45 Percent of Population 38.2 39 40 35 30.2 30 26.5 25 21.3 20 15 10 5 0 Male Female NH White NH Black Hispanic Prevalence of students in grades 9-12 who met currently recommended levels of physical activity during the past 7 days by race/ ethnicity and sex (YRBS: 2005). Source: MMWR. 2006;55:No. SS-5. NH – non-Hispanic. Note: “Currently recommended levels” is defined as activity that increased their heart rate and made them breathe hard some of the time for a total of at least 60 minutes/day on 5 or more of the 7 days preceding the survey.
  • 70. International Comparisons in CVD Morbidity and Mortality • CVD accounts for 25-45% of deaths among different countries • 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) • USA ranks 16th for both men (413) and women (201)
  • 71. Secular Trends in CHD and Stroke Mortality • 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. • Stroke death rates declined most in Australia, Italy, and France (8-9%), USA about 3%.
  • 72. 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
  • 73. 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
  • 74. 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
  • 75. 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
  • 76. Migrant Studies • 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
  • 77. Approaches to Primary and Secondary Prevention of CVD • Primary prevention involves prevention of onset of disease in persons without symptoms. • Primordial prevention involves the prevention of risk factors causative o the disease, thereby reducing the likelihood of development of the disease. • Secondary prevention refers to the prevention of death or recurrence of disease in those who are already symptomatic
  • 78. Risk Factor Concepts in Primary Prevention • Nonmodifiable risk factors include age, sexc, race, and family history of CVD, which can identify high-risk populations • Behavioral risk factors include sedentary lifestyle, unhealthful diet, heavy alcohol or cigarette consumption. • Physiological risk factors include hypertension, obesity, lipid problems, and diabetes, which may be a consequence of behavioral risk factors.
  • 79. Population vs. High-Risk Approach • Risk factors, such as cholesterol or blood pressure, have a wide bell-shaped distribution, often with a “tail” of high values. • 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”. • 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. • Significant reduction in the population burden of CVD can occur only from a “population approach” shifting the entire population distribution to lower levels.
  • 80. Pyramid of Risk (Werner et al. Canadian Journal of Cardiology 1998; 14(Suppl) B:3B-10B)
  • 81. Expected Shifts in Cholesterol Distribution from High-Risk, Population, and Combined Approaches
  • 82. Population and Community- Wide CVD Risk Reduction Approaches • Populations with high rates of CVD are those with Western lifestyles of high-fat diets, physical inactivity, and tobacco use. • Targets of a population-wide approach must be these behaviors causative of the physiologic risk factors or directly causative of CVD. • Requires public health services such as surveillance (e.g.,BFRSS), education (AHA, NCEP), organizational partnerships (Singapore Declaration), and legislation/policy (Anti-Tobacco policies) • Activities in a variety of community settings: schools, worksites, churches, healthcare facilities, entire communities
  • 83. A conceptual framework for public health practice in CVD prevention. (From Pearson et al., J Public Health. 2001; 29:69 –78)
  • 84. Communitywide CVD Prevention Programs • 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 • North Karelia (1972-) showed public education campaign to reduce smoking, fat consumption, blood pressure, and cholesterol • Stanford 5-City Project (1980-86) showed reductions in smoking, cholesterol, BP, and CHD risk • Minnesota Heart Health Program (1980-88) showed some increases in physical activity and in women reductions in smoking
  • 85. Materials Developed for US Community Intervention Trials • Mass media, brochures and direct mail • Events and contests • Screenings • Group and direct education • School programs and worksite interventions • Physician and medical setting programs • Grocery store and restaurant projects • Church interventions • Policies
  • 86. Individual and High-Risk Approaches • 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 • Barriers exist in the community and healthcare setting that prevent efficient risk reduction • Surveys of CVD prevention-related services show disappointing results regarding cholesterol- lowering therapy, smoking cessation, and other measures of risk reduction
  • 87. • Examination: Presentation – Height: 6 ft 2 in – Weight: 220 lb (BMI 28 kg/m2) – Waist circumference: 41 in – BP: 150/88 mm Hg – P: 64 bpm – RR: 12 breaths/min • Cardiopulmonary exam: 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
  • 88. Risk Assessment Count major risk factors • For patients with multiple (2+) risk 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%
  • 89. ATP III Assessment of CHD Risk For persons without known CHD, other forms of atherosclerotic disease, or diabetes: • Count the number of risk factors: – Cigarette smoking – Hypertension (BP 140/90 mmHg or on antihypertensive medication) – Low HDL cholesterol (<40 mg/dL)† – Family history of premature CHD  CHD in male first degree relative <55 years  CHD in female first degree relative <65 years – Age (men 45 years; women 55 years) • 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) Expert Panel on Detection, Evaluation, and Treatment of © 2001, Professional Postgraduate Services® High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497. www.lipidhealth.org
  • 90. ATP III Framingham Risk Scoring Step 1: Age Assessing CHD Risk in Men Years Points Step 4: Systolic Blood Pressure Step 6: Adding Up the Points 20-34 -9 Systolic BP Points Points Age 35-39 -4 (mm Hg) if Untreated if Treated Total cholesterol 40-44 0 <120 0 0 HDL-cholesterol 45-49 3 120-129 0 1 Systolic blood pressure 50-54 6 130-139 1 2 Smoking status 55-59 8 140-159 1 2 Point total 60-64 10 160 2 3 65-69 11 70-74 12 Step 7: CHD Risk 75-79 13 Point Total 10-Year Risk Point Total 10-Year Risk Step 2: Total Cholesterol <0 <1% 11 8% 0 1% 12 10% TC Points at Points at Points at Points 1 1% 13 12% at Points at (mg/dL) Age 20-39 Age 40-49 Age 50-59 Age 60-69 Age 2 1% 14 16% 70-79 3 1% 15 20% <160 0 0 0 0 0 4 1% 16 25% 160-199 4 3 2 1 0 5 2% 17 30% 200-239 7 5 3 1 0 6 2% 240-279 9 6 4 2 1 7 3% Step 3: HDL-Cholesterol 280 11 8 5 3 1 8 4% HDL-C 9 5% (mg/dL) Points Step 5: Smoking Status 10 6% 60 -1 Points at Points at Points at Points 50-59 0 at Points at 40-49 1 Age 20-39 Age 40-49 Age 50-59 Age 60-69 Age 70-79 <40 2 Nonsmoker 0 0 0 0 0 Note: Risk estimates were derivedfrom the experience8of Smoker the Framingham Heart Study, 5 3 1 1 a predominantly Caucasian population in Massachusetts, USA. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. © 2001, Professional Postgraduate Services® www.lipidhealth.org JAMA. 2001;285:2486-2497.
  • 91. ATP III Framingham Risk Scoring Assessing CHD Risk in Women Step 4: Systolic Blood Pressure Step 6: Adding Up the Points Step 1: Age Systolic BP Points Points Age Years Points (mm Hg) if Untreated if Treated Total cholesterol 20-34 -7 <120 0 0 HDL-cholesterol 35-39 -3 120-129 1 3 Systolic blood pressure 40-44 0 130-139 2 4 Smoking status 45-49 3 140-159 3 5 50-54 6 Point total 160 4 6 55-59 8 60-64 10 Step 7: CHD Risk 65-69 12 Point Total 10-Year Risk Point Total 10-Year 70-74 14 Risk 75-79 16 Step 2: Total Cholesterol <9 <1% 20 11% 9 1% 21 14% TC Points at Points at Points at Points 10 1% 22 17% at Points at (mg/dL) Age 20-39 Age 40-49 Age 50-59 Age 60-69 Age 11 1% 23 22% 70-79 12 1% 24 27% <160 0 0 0 0 0 13 2% 25 30% 160-199 4 3 2 1 1 14 2% 200-239 8 6 4 2 1 15 3% 240-279 11 8 5 3 2 16 4% Step 3: HDL-Cholesterol 280 13 10 7 4 2 17 5% HDL-C 18 6% (mg/dL) Points Step 5: Smoking Status 19 8% 60 -1 Points at Points at Points at Points 50-59 0 at Points at 40-49 1 Age 20-39 Age 40-49 Age 50-59 Age 60-69 Age 70-79 <40 2 Nonsmoker 0 0 0 0 0 Note: Risk estimates were derivedfrom the experience9of Smoker the Framingham Heart Study, 7 4 2 1 a predominantly Caucasian population in Massachusetts, USA. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. © 2001, Professional Postgraduate Services® www.lipidhealth.org JAMA. 2001;285:2486-2497.
  • 92. ATP III Framingham Risk Scoring Step 1: Age Men Women Years Points Years Points 20-34 -9 20-34 -7 35-39 -4 35-39 -3 40-44 0 40-44 0 45-49 3 45-49 3 50-54 6 50-54 6 55-59 8 55-59 8 60-64 10 60-64 10 65-69 11 65-69 12 70-74 12 70-74 14 75-79 13 75-79 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
  • 93. ATP III Framingham Risk Scoring Step 2: Total Cholesterol 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 atPoints 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 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 © 2001, Professional Postgraduate Services® Cholesterol in Adults. JAMA. 2001;285:2486-2497. www.lipidhealth.org
  • 94. ATP III Framingham Risk Scoring Step 3: HDL-Cholesterol Men Women HDL-C HDL-C (mg/dL) Points (mg/dL) Points 60 -1 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
  • 95. ATP III Framingham Risk Scoring Step 4: Systolic Blood Pressure 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 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 © 2001, Professional Postgraduate Services® www.lipidhealth.org Cholesterol in Adults. JAMA. 2001;285:2486-2497.
  • 96. ATP III Framingham Risk Scoring MenStep 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 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 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
  • 97. ATP III Framingham Risk Scoring Step 6: Adding Up the Points (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
  • 98. ATP III Framingham Risk Scoring Step 7: CHD Risk for Men 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% 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. © 2001, Professional Postgraduate Services® www.lipidhealth.org
  • 99. What is WJC’s 10-year absolute risk of fatal/nonfatal MI? • A 12% absolute risk is derived from points assigned in Framingham Risk Scoring to: – Age: 6 – TC: 3 – HDL-C: 2 – SBP: 2 – 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.
  • 100. ATP III Framingham Risk Scoring Step 7: CHD Risk for 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: 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. © 2001, Professional Postgraduate Services® www.lipidhealth.org
  • 101. CHD Risk Equivalents • Risk for major coronary events equal to that in established CHD • 10-year risk for hard CHD >20% Hard CHD = myocardial infarction + coronary death
  • 102. Diabetes as a CHD Risk Equivalent • 10-year risk for CHD 20% • High mortality with established CHD – High mortality with acute MI – High mortality post acute MI
  • 103. CHD Risk Equivalents • Other clinical forms of atherosclerotic disease (peripheral arterial disease, abdominal aortic aneurysm, and symptomatic carotid artery disease) • Diabetes • Multiple risk factors that confer a 10- year risk for CHD >20%