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Public HealthBETTINA PIKO, M.D., Ph.D.
   - Leading cause of mortality in developed    countries and a rising tendency in developing    countries (disease of ci...
   - Coronary heart disease (CHD, ischemic heart    disease, heart attack, myocardial infarction,    angina pectoris)   ...
   - Detection of the occurrence and distribution    of CVD in populations, surveillance,    monitoring, trends of change...
   1., Descriptive epidemiology:   = Describing distribution of cardiovascular    disease by means of certain characteri...
   In the world: CVD deaths account for one third    of all deaths (25-50% depending on the level of    economic developm...
   Question: What is the relative amount of CVD in    death rates in different age groups?   - Early lesions of blood ve...
PROPORTION OF MORTALITY IN DIFFERENT AGE-GROUPS (MEN)100%                                  4,7%                        14,...
PROPORTION OF MORTALITY IN DIFFERENT AGE-GROUPS (WOMEN)100%                                    4,8%                       ...
   Question: What is the relative amount of CVD in death    rates in women and men?   - Widespread idea: CVD is often th...
   Question: What is the relative amount of CVD in    death rates in different ethnic groups?   - In the US: increased c...
   Question: What is the relative amount of    CVD in different geographical places? What    are the time trends? Interna...
   Developed countries: decreasing tendencies     (e.g, USA: 30% between 1988-98, Sweden: 42%)   - improvement of lifest...
   Aims:   a., Where are the rates higher or    lower?   b., Interpretation of time trends   c., Inequalities in cardi...
          Austria         Denmark          Finland          France          Greece          ItalyNetherlands             S...
                            Croatia                                 Hungary                                               ...
          Finland          Hungary      EU-15          average
   Over 300 risk factors have been associated with    coronary heart disease, hypertension and stroke   Approx. 75% of C...
Major modifiable risk factors   Other modifiable risk factors-   High blood pressure         -   Low socioeconomic status-...
   - Systolic blood pressure >140 Hgmm and/or a    diastolic blood pressure > 90 Hgmm   - Free of clinical symptoms for ...
   Development: Rheumatic fever usually follows    an untreated beta-haemolytic streptococcal    throat        infection ...
   - Se cholesterol: structure and functioning of    blood vessels, atherosclerotic plaques   - Altering functions of ch...
European             US guidelines                    guidelinesTotal cholesterol   <5.0 mmol/l          <240 mg/dl (6.2 m...
   - The link between smoking and CVD (mainly    CHD) was identified in 1940   - Greatest risk: initiation < 16 years  ...
   - Regular physical activity: protective factor   - Intensity and duration (150 minutes/week    intermediate or 60 min...
   - Body Mass Index: > 25: overweight, > 30:    obesity   - A modern ”epidemic”: More than 60% of    adults in the US a...
   - Psychological factors (Type A behavior,    hostility)   - Depression and CVD: bidirectional link   a., depression ...
   Primordial: Social, legal and other (often    nonmedical) activities which may lead to a    lowering of risk factors (...
   The individual approach (detecting those at    greatest risk): lifestyle guidelines (e.g., smoking    cessation)   Th...
•  What may be the reasons for the decliningCVD incidence rates?• At the same time that there has been anepidemic of obesi...
Epide.of cvd
Epide.of cvd
Epide.of cvd
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Epide.of cvd

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  • Dr. Piko provides and excellent overview of what we know about the epidemiology of CVD (Supercourse) If you see (Supercourse), this means that one of the Supercourse team annotated that slide, not the author. Some URLs also provided by Supercourse team. Original PowerPoint file of this lecture
  • http://circ.ahajournals.org/cgi/content/full/93/9/1755 Cardiovascular Disease Epidemiology A Journey From the Past Into the Future Frederick H. Epstein
  • CVD is the leading global cause of death. What is important is that it is not inevitable that we need to die from CVD (Supercourse)
  • CVD represents a heterogeneous disorder (Supercourse)
  • CVD epidemiology has played a major role in determining the cases of CVD and prevention (Supercourse)
  • Epidemiologic tools ranges from descriptive epidemiology studies to experimental interventions (Supercourse)
  • CVD accounts for most of the mortality in the world (Supercourse)
  • http://www.americanheart.org/presenter.jhtml?identifier=3065525 Joint Conference - 50th Cardiovascular Disease Epidemiology and Prevention - and - Nutrition, Physical Activity and Metabolism - 2010
  • As we age, CHD takes over more and more of the mortality (Supercourse)
  • Virtually the same pattern occurs for women (Supercourse)
  • CVD is not just a disease of men, as it prominent as well in women (Supercourse)
  • There has been an amazing decline in mortality in the US and Europe in the past 50 years. (Supercourse)
  • There are consistent difference by ethnicity. African Americans appear to have the highest risk, whites next, and Pacific Islanders and Native Americans the lowest. Migrant students have consistently shown increases in CHD risk when Japanese migrate to Hawaii, for example (Supercourse)
  • http://www.pitt.edu/~super1/Descriptive%20Epidemiology/de.htm DESCRIPTIVE EPIDEMIOLOGY for Public Health Professionals by Ian Rockett
  • In the US and most developed countries there has been a marked reduction in the past 40 year, at the same time there has been a tendency to see increases in developing countries (Supercourse)
  • We are seeing the highest rates in Russia, why might this be occurring? (Supercourse)
  • The largest decline has been seen in Finland, why might this be? (Supercourse)
  • Eastern Europe, especially Russia has seen a large increase in CHD (Supercourse)
  • There has been an enormous number of risk factors identified. We in epidemiology are most interested in the risk factors that can be modified (Supercourse)
  • http://www.biostatem.com/english/epidemiology/epidemiology.htm Analytical epidemiology aims to research and study risk and protector factors of diseases.
  • Hypertension is a very important risk factor as it is wide spread, and relatively easy to control (Supercourse)
  • RF as a chronic disease was exceptionally important at the early part of the 20 th century. It has markedly declined, at the same time that CVA has increased. (Supercourse)
  • Physical activity both on the job and voluntary has markedly gone down. (Supercourse)
  • The exact relationship of BMI to CVD risk is not very strong, and could be J shaped (Supercourse)
  • When developing prevention programs one needs to attack the different forms of prevention (Supercourse)
  • Many believe that the Population wide approach is the most cost-effective (Supercourse)
  • We would appreciate your help with evaluating the content of this course. Please send completed Evaluation Form to [email_address]   with the subject &quot;chronic disease supercourse evaluation&quot;    If you have any comments or questions, please send a message to [email_address]     
  • Transcript of "Epide.of cvd"

    1. 1. Public HealthBETTINA PIKO, M.D., Ph.D.
    2. 2.  - Leading cause of mortality in developed countries and a rising tendency in developing countries (disease of civilization) - A major impact on life expectancy - Significantly contributes to morbidity and death rates in the middle aged population: potential life years lost, common cause of premature death, labor force (economic costs), family life - Morbidity: nearly 30% of all disability cases - Contributes to deterioration of the quality of life
    3. 3.  - Coronary heart disease (CHD, ischemic heart disease, heart attack, myocardial infarction, angina pectoris) - Cerebrovascular disease (stroke, TIA, transient ischemic attack) - Hypertensive heart disease - Peripheral vascular disease - Heart failure - Rheumatic heart disease (streptococcal infection) - Congenital heart disease - Cardiomyopathies
    4. 4.  - Detection of the occurrence and distribution of CVD in populations, surveillance, monitoring, trends of changes - Study of the natural history of CVD - Formulation and testing of etiological hypotheses (risk factors) - Contribution to the development of cardiovascular prevention programs and the measurement of their effectiveness
    5. 5.  1., Descriptive epidemiology: = Describing distribution of cardiovascular disease by means of certain characteristics such as : PERSON (i.e., age, gender, ethnicity) TIME and PLACE 2., Analytic epidemiology = Analyzing relationships between CVD and risk factors (which elevate the probability of a disease at population level), risk model and multicausal developments 3., Experimental epidemiology/Interventions = Strategies of cardiovascular prevention (primordial, primary, secondary, tertiary; individual and community levels)
    6. 6.  In the world: CVD deaths account for one third of all deaths (25-50% depending on the level of economic development) among which 50%: coronary deaths CVD made up 16.7 million of global deaths in 2002, among which 7 million due to coronary heart disease, 6 million due to stroke Distribution of types of CVD in global deaths : Global cardiovascular deaths in 2002: 16.7 million among which: coronary heart disease 7.2 million > stroke 6.0 million > 0.9 million hypertensive heart disease > 0.4 million inflammatory heart disease > 0.3 million rheumatic heart disease > 1.9 million other CVD
    7. 7.  Question: What is the relative amount of CVD in death rates in different age groups? - Early lesions of blood vessel, atherosclerotic plaques: around 20 years - adult lifestyle patterns usually start in childhood and youth (smoking, dietary habits, sporting behavior, etc.) - Increase in CVD morbidity and mortality: in age-group of 30-44 years - Premature death (<64 years of age, or 25-64 years): in the elderly population more difficult to interpret death rate due to multiple ill health causes
    8. 8. PROPORTION OF MORTALITY IN DIFFERENT AGE-GROUPS (MEN)100% 4,7% 14,0% 14,9%90%80% 26,0% 61,5% 24,6%70%60% external others50% 26,9% cancer CVD40% 22,5% 55,8%30%20% 32,7% 11,4%10% 4,6% 0% 1-24 yrs 25-64 yrs >65 yrs
    9. 9. PROPORTION OF MORTALITY IN DIFFERENT AGE-GROUPS (WOMEN)100% 4,8% 8,2%90% 18,3% 40,0% 24,0%80% 12,2%70%60% external 36,5% others50% 35,0% cancer CVD40% 64,7%30%20% 17,7% 31,3%10% 7,3% 0% 1-24 yrs 25-64 yrs >65 yrs
    10. 10.  Question: What is the relative amount of CVD in death rates in women and men? - Widespread idea: CVD is often thought to be a disease of middle-aged men. - Cardiovascular mortality (fatal cases) are more common among men. However, CVD affect nearly as many women as men, albeit at an older age - Women: special case (WHO, 2004) a., Higher risk in women than men (smoking, high triglyceride levels) b., Higher prevalence of certain risk factors in women (diabetes mellitus, depression) c., Gender-specific risk factors (risks for women only) (oral contraceptives, hormone replacement therapy, polycystic ovary syndrome)
    11. 11.  Question: What is the relative amount of CVD in death rates in different ethnic groups? - In the US: increased cardiovascular disease deaths in African-American and South-Asian populations in comparison with Whites - Increased stroke risk in African-American, some Hispanic American, Chinese, and Japanese populations - Migration: Ni-Hon-San Study: Japanese living in Japan had the lowest rates of CHD and cholesterol levels, those living in Hawaii had intermediate rates for both, those living in San Francisco had the highest rates for both
    12. 12.  Question: What is the relative amount of CVD in different geographical places? What are the time trends? International and regional characteristics of distribution SDR: Standardized Death Rate Direct mode of standardization, using the age distribution of a hypothetical European standard population Premature death rates for comparison purposes (<64 years of age)
    13. 13.  Developed countries: decreasing tendencies (e.g, USA: 30% between 1988-98, Sweden: 42%) - improvement of lifestyle factors, for example, a decrease of smoking and a higher level of health consciousness in many developed countries - better diagnostic and therapeutic procedures (e.g., bypass surgeries, hypertension screening, pharmacological treatment of hypertension and hypercholesterinaemia, access to health care) Developing countries: increasing tendencies - increasing longevity, urbanization, and western type lifestyle
    14. 14.  Aims: a., Where are the rates higher or lower? b., Interpretation of time trends c., Inequalities in cardiovascular death
    15. 15.      Austria     Denmark     Finland     France     Greece     ItalyNetherlands         Spain   Switzerland     United     Kingdom  EU-15 average
    16. 16.          Croatia        Hungary                           Romania                       Russian   Federation                       Slovakia           EU-15                     average (MSs   prior 1.5.2004)            
    17. 17.      Finland     Hungary EU-15     average
    18. 18.  Over 300 risk factors have been associated with coronary heart disease, hypertension and stroke Approx. 75% of CVD can be attributed to conventional risk factors Risk factors of great public health significance: - high prevalence in many populations - great independent impact on CVD risk - their control and treatment result in reduced CVD risk Developing countries: double burden of risks (problems of undernutrition and infections + CVD risks)
    19. 19. Major modifiable risk factors Other modifiable risk factors- High blood pressure - Low socioeconomic status- Abnormal blood lipids - Mental ill health (depression)- Tobacco use - Psychosocial stress- Physical inactivity - Heavy alcohol use- Obesity - Use of certain medication- Unhealthy diet - Lipoprotein(a)- Diabetes mellitusNon-modifiable risk factors ”Novel” risk factors- Age - Excess homocysteine in blood- Heredity or family history - Inflammatory markers (C-- Gender reactive protein)- Ethnicity or race - Abnormal blood coagulation (elevated blood levels of fibrinogen)
    20. 20.  - Systolic blood pressure >140 Hgmm and/or a diastolic blood pressure > 90 Hgmm - Free of clinical symptoms for many years (screening) - In most countries, up to 30 percent of adults suffering, increasing with age in civilized countries - Positive family history - Dietary habits (a high intake of salt, processed food, low levels of water hardness, high thyramine content of food, alcohol use) - Modern lifestyle (increased sympathetic activity, psychosocial stress, leading position in job)
    21. 21.  Development: Rheumatic fever usually follows an untreated beta-haemolytic streptococcal throat infection in children As a consequence, the heart valves are permanently damaged which may progress to heart failure Today mostly affects children in developing countries, linked to poverty, inadequacy of health care access Occurrence: 12 million people currently affected by rheumatic fever and RHD, two-thirds are children (5-15 years), for example: approx. 1 000 000 in Sub-Saharan Africa, 700 000 in South- Central Asia, 176 000 in China, 150 000 in North Africa, 40 000 in Eastern Europe (!)
    22. 22.  - Se cholesterol: structure and functioning of blood vessels, atherosclerotic plaques - Altering functions of cholesterol fractions (LDL: risk, HDL: protection) - Estrogen: tends to raise HDL-cholesterol and lower LDL-cholesterol, protection for women in reproductive age - Partially genetic determination of metabolism, partially dependent of nutrition (egg, meats, dairy products)
    23. 23. European US guidelines guidelinesTotal cholesterol <5.0 mmol/l <240 mg/dl (6.2 mmol/l)LDL-cholesterol <3.0 mmol/l <160 mg/dl (3.8 mmol/l)HDL-cholesterol >=1.0 mmol/l (men) >=40 mg/dl (1 mmol/l) >=1.2 mmol/l (women)Triglycerides <1.7 mmol/l <200 mg/dl (2.3 mmol/l)(fasting)
    24. 24.  - The link between smoking and CVD (mainly CHD) was identified in 1940 - Greatest risk: initiation < 16 years - Passive smoking: additional risk - Women smokers: are at higher risk of CHD and CVD than male smokers - Several mechanisms: damages the endothelium lining, increases atherosclerotic plaques, raises LDL and lowers HDL, promotes artery spasms, raises oxigen demand of the heart muscle - Nicotine accelerates the heart rate (RR), and raises blood pressure
    25. 25.  - Regular physical activity: protective factor - Intensity and duration (150 minutes/week intermediate or 60 minutes/week heavy) - Modernization, urbanization, mechanized transport: sedentary lifestyle (60% of global population) - Raises CVD risk and also the development of other risk factors (glucose metabolism, diabetes mellitus, blood coagulation, obesity, high blood pressure, worsening lipid profile) - Physical activity: helps reduce stress, anxiety and depression
    26. 26.  - Body Mass Index: > 25: overweight, > 30: obesity - A modern ”epidemic”: More than 60% of adults in the US are overweight or obese, in China: 70 million overweight people - Elevates the risk of both CVD and diabetes mellitus - Diabetes mellitus: damages both peripheral and coronary blood vessels -Unhealthy diet: low fruit and vegetable, fiber content, and high saturated fat intake, refined sugar
    27. 27.  - Psychological factors (Type A behavior, hostility) - Depression and CVD: bidirectional link a., depression may increase the risk of CVD and worsen recovery process b., CVD may induce depression - Low socioeconomic status (SES): a., in developed countries: less educated and lower SES groups (accumulation of risk factors) b., in developing countries: more educated and higher SES groups (western lifestyle)
    28. 28.  Primordial: Social, legal and other (often nonmedical) activities which may lead to a lowering of risk factors (e.g., socioeconomic development, smoke-free restaurants) Primary: Controlling risk factors contributing to CVD (health education programs, anti- smoking campaign, sports programs, nutrition counselling, regular check of blood pressure and certain blood parameters, e.g., cholesterol, blood lipids, glucose) Secondary: Screening and treatment of symptomatic patients, set up personal risk profile Tertiary: Cardiovascular rehabilitation, prevention of recurrence of CVD (new heart attack: 5-7 times higher risk among CVD patients)
    29. 29.  The individual approach (detecting those at greatest risk): lifestyle guidelines (e.g., smoking cessation) The population-wide approach: (the whole population, western lifestyle ) Example for community-wide CV prevention programs: - Framingham Heart Study (1948-) Framingham Risk Scoring - North-Karelia Project (1972-) Finland - Stanford Projects (1972-75, 1980-86) USA - Minnesota Cardiovascular Health Program (1980-88) USA - Multiple Risk factor Intervention Trial (1972- 79) USA
    30. 30. • What may be the reasons for the decliningCVD incidence rates?• At the same time that there has been anepidemic of obesity, the rates of CVD hasmarkedly declined. Why hasn’t CVD go up inthe population as obesity has skyrocketed?•Define the steps to prevent CHD
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