4,6%11,4%22,5%61,5%32,7%26,9%26,0%14,0%55,8%24,6%14,9%4,7%0%10%20%30%40%50%60%70%80%90%100%1-24 yrs 25-64 yrs >65 yrsPROPORTION OF MORTALITY IN DIFFERENT AGE-GROUPS (MEN)externalotherscancerCVD
7,3%17,7%35,0%40,0%31,3%36,5%24,0%8,2%64,7%12,2%18,3%4,8%0%10%20%30%40%50%60%70%80%90%100%1-24 yrs 25-64 yrs >65 yrsPROPORTION OF MORTALITY IN DIFFERENT AGE-GROUPS (WOMEN)externalotherscancerCVD
Major Risk Factors• Cigarette smoking• Elevated total or LDL-cholesterol• Hypertension• Low HDL cholesterol (<40 mg/dL)†• Family history of premature CHD– CHD in male first degree relative <55years– CHD in female first degree relative <65years• Age (men 45 years; women 55 years)
Other Recognized Risk Factors• Obesity: Body Mass Index (BMI)–Weight (kg)/height (m2)• Physical inactivity: most expertsrecommend at least 30 minutesmoderate activity at least 4-5days/week
Reducing Your Risk ForCardiovascular Diseases• Risks you can control– Avoid tobacco– Cut back on saturated fat and cholesterol– Maintain a healthy weight– Modify dietary habits– Exercise regularly– Control diabetes– Control blood pressure• Systolic – upper number• Diastolic – lower number– Manage stress
Reducing Your Risk ForCardiovascular Diseases• Risks you cannot control–Heredity–Age–Gender–Race
Women And CardiovascularDisease• Estrogen– Once estrogen production stops, risk for CVDdeath increases• Diagnostic and therapeutic differences– Delay in diagnosing possible heart attack– Complexity in interpreting chest pain in women– Less aggressive treatment of female heart attackvictims– Smaller coronary arteries in women• Gender bias in CVD research – typically CVDresearch has been conducted on male subjects
Approaches to Primary andSecondary Prevention of CVD• Primary prevention involves prevention ofonset of disease in persons without symptoms.• Primordial prevention involves the preventionof risk factors causative o the disease, therebyreducing the likelihood of development of thedisease.• Secondary prevention refers to the preventionof death or recurrence of disease in those whoare already symptomatic
Risk Factor Concepts in PrimaryPrevention• 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 cigaretteconsumption.• Physiological risk factors include hypertension,obesity, lipid problems, and diabetes, which may be aconsequence of behavioral risk factors.
Population vs. High-Risk Approach• Risk factors, such as cholesterol or blood pressure, have awide bell-shaped distribution, often with a “tail” of highvalues.• The “high-risk approach” involves identification and intensivetreatment of those at the high end of the “tail”, often atgreatest risk of CVD, reducing levels to “normal”.• But most cases of CVD do not occur among the highest levelsof a given risk factor, and in fact, occur among those in the“average” risk group.• Significant reduction in the population burden of CVD canoccur only from a “population approach” shifting the entirepopulation distribution to lower levels.
Population and Community-WideCVD Risk Reduction Approaches• Populations with high rates of CVD are those with Westernlifestyles of high-fat diets, physical inactivity, and tobacco use.• Targets of a population-wide approach must be these behaviorscausative of the physiologic risk factors or directly causative ofCVD.• Requires public health services such as surveillance(e.g.,BFRSS), education (AHA, NCEP), organizationalpartnerships (Singapore Declaration), and legislation/policy(Anti-Tobacco policies)• Activities in a variety of community settings: schools, worksites,churches, healthcare facilities, entire communities
Communitywide CVD PreventionPrograms• Stanford 3-Community Study (1972-75) showed massmedia vs. no intervention in high-risk residents toresult in 23% reduction in CHD risk score• North Karelia (1972-) showed public educationcampaign to reduce smoking, fat consumption, bloodpressure, and cholesterol• Stanford 5-City Project (1980-86) showed reductions insmoking, cholesterol, BP, and CHD risk• Minnesota Heart Health Program (1980-88) showedsome increases in physical activity and in womenreductions in smoking
Materials Developed for USCommunity 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
Individual and High-RiskApproaches• Primary Prevention Guidelines (1995) and SecondaryPrevention Guidelines (Revised 2001) released by theAmerican Heart Association provide advice regarding riskfactor assessment, lifestyle modification, andpharmacologic interventions for specific risk factors• Barriers exist in the community and healthcare settingthat prevent efficient risk reduction• Surveys of CVD prevention-related services showdisappointing results regarding cholesterol-loweringtherapy, smoking cessation, and other measures of riskreduction