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Coronary Heart Disease :
Epidemiology
Presented By
Dr Garima Gupta
MBBS , MD Post Graduate student
University College Of M...
Cardio-Vascular Disease
• Cardiovascular diseases (CVDs) are a group of disorders of the
heart and blood vessels.
Coronar...
Proportions of death from CVD due to coronary heart
disease, cerebrovascular disease and other CVDs in
males
Global atlas ...
Proportions of death from CVD due to coronary heart
disease, cerebrovascular disease and other CVDs in
females
Global atla...
CAD-epidemiology
• Descriptive epidemiology - Describing distribution of
coronary artery disease by means of certain chara...
Coronary Artery Disease
• Enas EA. How to Beat the Heart Disease Epidemic among South Asians: A Prevention and
Management ...
Descriptive Epidemiology
Descriptive Epidemiology :
Distribution Patterns in the World
Disease burden (World)
(expressed as percentage of DALYs Lost)
• World Health Organisation ( WHO) Report 2002
0.00%
1.00%
...
India
• Indians with Coronary Artery Disease (in millions)
• * - 780 million adults > 20 years of age
• ** - 800 million a...
Deaths due to CAD (India)
• * - 780 million adults > 20 years of age
• ** - 800 million adults > 20 years of age
• Nationa...
Deaths from coronary artery disease
Coronary heart disease mortality (in percentages) between
Developed Nations and Developing Nations (1990 and 2020)
44%
31%...
World trends and International Comparisons
• Cardiovascular disease (CVD) and coronary heart disease (CHD) deaths
(million...
• EME- Established Market Economies
1.18
1.59
2.03
2.58
0.76
0.99
1.15
1.37
1.67
1.84 1.87
1.95
0
0.5
1
1.5
2
2.5
3
1990 2...
Model of the Stages of Epidemiologic
Transition
Stages of
development
Deaths
from
CVD
Predominant CVD and Risk Factor Regi...
• Regression Dilution Bias
• Lag Effect
Economic burden
Cost
of CAD
Cost to the
individual
and family
Cost to
government
of health
care
Cost of
“HUMAN
LIFE”
Cost ...
• A cross-sectional study was conducted by Huffman et al
Patients in Argentina, China, India, and Tanzania bear a
signific...
Descriptive Epidemiology :
Distribution Patterns as per Age and Gender
• National Health and Nutrition Examination Survey:...
Descriptive Epidemiology :
Distribution Patterns as per Gender
• Higher rates of coronary heart disease among men compared...
Descriptive Epidemiology :
Distribution Patterns as per Ethnicity
Prevalence of CVD for specific degrees of carotid athero...
• Although both Chinese and Asian Indians in the US are
classified as Asian Americans, they are diametrically opposite
in ...
Asian-Indian paradox
• Asian Indian paradox refers to the excess burden of
heart disease among Asian Indians despite havin...
• Coronary artery disease (CAD) rates and lipoprotein levels are
similar among vegetarians and non-vegetarians. This is in...
Analytical epidemiology
Non Modifiable factors and Modifiable factors
Non-Modifiable factors Modifiable factors
Advancing Age High Blood Pressure
...
Other Modifiable Risk Factors Novel Risk Factors
Socio-economic Status Excess homocysteine in blood
Alcohol Use Abnormal b...
Genetics
• Recent genome wide association studies indicate that genetic
factors predisposing to heart attack in patients w...
• A study which compared 12,393 individuals with coronary
artery disease (CAD) with 7383 controls (without any
narrowing o...
Blood Pressure
• High blood pressure (hypertension) is one of the most
important preventable causes of premature death wor...
ROLE OF HDL-C AND LDL-C
HDL-C
< 40 mg/dl in men
< 50 mg/dl in
women
LDL-C > 100 mg/dl
Triglycerides >150
mg/dl
BALANCE OF ...
Lipoprotein (a) “The Deadly Cholesterol”
• Lipoprotein (a) is a strong, putative, and causal risk factor for
heart disease...
Multiplicative effects of Lp(a)
• Enas EA, Chacko V, Senthilkumar A, Puthumana N, Mohan V. Elevated lipoprotein(a)–a genet...
Tobacco
• Tobacco causes a fifth of cardiovascular disease worldwide.
• India is the home to 12% of world’s smokers. (WHO)...
Physical inactivity
• A coalescence of anthropological estimations of Homo
sapiens’ phenotypes in the late Palaeolithic er...
Obesity
• Abdominal girth and waist-to-hip ratio are useful indicators of
obesity.
• The Body Mass Index (BMI), a measure ...
Diabetes and CAD
DIABETICS
12-40 times the rate of CAD as
in non-diabetic
More advanced atherosclerosis
. High blood gluco...
Socio-economic status
In developing countries, higher socioeconomic class has been
associated with a higher prevalence of ...
Psychological
• Contrary to common belief, type A personality is not
associated with an excess of coronary artery disease
...
hs-CRP
• Acute phase reactant ( inflammatory marker)
• CRP level has been proposed as biomarker for CVD and CAD
risk predi...
Vitamin-D
• Low vitamin D levels are highly associated with endothelial
dysfunction, atherosclerosis, heart attack, heart ...
Risk assessment scores
• Framingham risk score
• Lifetime risk
• Risk estimation by disease status
• SCORE (Systematic COr...
Interventional epidemiology
Primordial prevention
prevention of the risk factors for CVD,
such as efforts aimed to prevent
hypertension, obesity, or
d...
ABCDE Approach
• Oxford Textbook of Global Public Health
Aspirin / Anti-platelet therapy
Blood pressure monitoring
Cholest...
Three Pronged Approach
Individual
Policies/
legislati
on
Community/
population
Individual level
 Take moderate physical activity for a total of 30 minutes on
most days of the week.
 Avoid tobacco use...
Population / community level
• Significant health gains in cardiovascular health can be made
within short time spans, thro...
FINLAND
North Karelia Project
By 2005, CAD mortality in men and women
had declined by 80%.
POLAND
Mortality due to CAD fel...
Policies and Legislations
• Global Action Plan for the Prevention and Control
of NCDs 2013-2020
• National Programme For P...
Recommendations to address the
CAD epidemic in the Indian
subcontinent
Suggested policy interventions
• Establishment of a national regulatory agency to enforce
already existing tobacco control...
Suggested capacity building measures
• Development of research infrastructure and training of
clinical researchers.
• Esta...
Suggested research initiatives
• Generation of reliable statistics on prevalence and incidence
of CAD and its risk factors...
Prevention Paradox
Population at Low Risk /
Moderate Risk
High Risk
Population
Majority of cases
Minority
of cases
Barriers to prevention
• The physicians themselves need to be educated about the
importance of prevention and the patients...
Barriers….
• Reducing excess risk in South Asians requires multilevel,
positive, mainstream and targeted measures using mu...
Future
• Predictions are by their nature speculative. Nevertheless, this
much is certain: the global epidemic of cardiovas...
• “Live sensibly - among a thousand people,
only one dies a natural death; the rest
succumb to irrational modes of living....
Thank You
Objectives of NPCDCS
• 1) Prevent and control common NCDs through behaviour and
life style changes,
• 2) Provide early dia...
Strategies
• The Strategies to achieve above objectives are as follows:
• 1) Prevention through behaviour change
• 2) Earl...
Coronary heart disease - epidemiology
Coronary heart disease - epidemiology
Coronary heart disease - epidemiology
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Coronary heart disease - epidemiology

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Epidemiology of coronary heart disease- Global and Indian scenario

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Coronary heart disease - epidemiology

  1. 1. Coronary Heart Disease : Epidemiology Presented By Dr Garima Gupta MBBS , MD Post Graduate student University College Of Medical Sciences & GTB Hospital, Delhi 1
  2. 2. Cardio-Vascular Disease • Cardiovascular diseases (CVDs) are a group of disorders of the heart and blood vessels. Coronary heart disease/ Coronary artery disease Cerebrovascular disease Peripheral arterial disease Rheumatic heart disease Congenital heart disease Deep vein thrombosis and pulmonary embolism.
  3. 3. Proportions of death from CVD due to coronary heart disease, cerebrovascular disease and other CVDs in males Global atlas on cardiovascular disease prevention and control, World Health Organisation 11% 1% 2% 6% 34% 46% Other CVD Rheumatic Heart Disease Inflammatory Heart Disease Hypertensive Heart Disease Cerebrovascular Disease Coronary Heart6 Disease
  4. 4. Proportions of death from CVD due to coronary heart disease, cerebrovascular disease and other CVDs in females Global atlas on cardiovascular disease prevention and control, World Health Organisation 14% 1%2% 7% 37% 39% Other CVD Rheumatic Heart Disease Inflammatory Heart Disease Hypertensive Heart Disease Cerebrovascular Disease Coronary Heart Disease
  5. 5. CAD-epidemiology • Descriptive epidemiology - Describing distribution of coronary artery disease by means of certain characteristics such as : PERSON (i.e., age, gender, ethnicity) TIME and PLACE • Analytical epidemiology - Analysing relationships between CAD and risk factors (which elevate the probability of a disease at population level), risk model and multicausal developments • Interventional epidemiology - Strategies of cardiovascular prevention (primordial, primary, secondary, tertiary; individual and community levels)
  6. 6. Coronary Artery Disease • Enas EA. How to Beat the Heart Disease Epidemic among South Asians: A Prevention and Management Guide for Asian Indians and their Doctors. Downers Grove: Advanced Heart Lipid Clinic USA; 2010. TypeI • Young individuals < 50 years • Marked prematurity , severity • High prevalence of emerging risk factors TypeII • Older individuals > 65 years • Mild – moderate severity • High prevalence of traditional risk factors. TypeIII • Also known as “MIXED VARIETY” • Individuals between 50-65 years of age • Role of both classes of risk factors present.
  7. 7. Descriptive Epidemiology
  8. 8. Descriptive Epidemiology : Distribution Patterns in the World
  9. 9. Disease burden (World) (expressed as percentage of DALYs Lost) • World Health Organisation ( WHO) Report 2002 0.00% 1.00% 2.00% 3.00% 4.00% 5.00% 6.00% 7.00% 8.00% 9.00% HIV/AIDS CHD Stroke UDD RTA TB COPD Hearing loss PERCENTAGEOFDALYSLOST Males Females
  10. 10. India • Indians with Coronary Artery Disease (in millions) • * - 780 million adults > 20 years of age • ** - 800 million adults > 20 years of age • National Commission on Macroeconomics and Health. • Enas EA, Mehta J. Malignant coronary artery disease in young Asian Indians: thoughts on pathogenesis, prevention, and therapy. Coronary Artery Disease in Asian Indians (CADI) Study. Clin Cardiol. Mar 1995;18(3):131-135. Age 2010* 2015** Increase from 2010 to 2015 (%) All 47.0 61.8 32 <50 yrs of age 28.4 37.3 31 <40 yrs of age 17.4 23.0 32 <30 yrs of age 8.3 10.5 27
  11. 11. Deaths due to CAD (India) • * - 780 million adults > 20 years of age • ** - 800 million adults > 20 years of age • National Commission on Macroeconomics and Health. • Enas EA, Mehta J. Malignant coronary artery disease in young Asian Indians: thoughts on pathogenesis, prevention, and therapy. Coronary Artery Disease in Asian Indians (CADI) Study. Clin Cardiol. Mar 1995;18(3):131-135. Age 2010* 2015** Increase from 2010 to 2015 (%) All 2.3 2.9 26 < 50 years of age 1.14 1.5 32 < 40 years of age 0.70 0.92 31 < 30 years of age 0.33 0.42 27
  12. 12. Deaths from coronary artery disease
  13. 13. Coronary heart disease mortality (in percentages) between Developed Nations and Developing Nations (1990 and 2020) 44% 31% 56% 69% 0% 10% 20% 30% 40% 50% 60% 70% 80% 1990 2020 Developed nations Developing Nations
  14. 14. World trends and International Comparisons • Cardiovascular disease (CVD) and coronary heart disease (CHD) deaths (millions) in India, China, and established market economies (EME) from the Global Burden of Diseases Study. (Ezzati et al., 2004) 1990 2000 2010 2020 INDIA CHIN A EME INDIA CHIN A EME INDIA CHINA EME INDI A CHI NA EME CVD 2.26 2.57 3.18 3.01 3.30 3.49 3.80 3.81 3.53 4.77 4.53 3.66 CAD 1.18 0.76 1.67 1.59 0.99 1.84 2.03 1.15 1.87 2.58 1.37 1.95 119 % Increase
  15. 15. • EME- Established Market Economies 1.18 1.59 2.03 2.58 0.76 0.99 1.15 1.37 1.67 1.84 1.87 1.95 0 0.5 1 1.5 2 2.5 3 1990 2000 2010 2020 Deathsinmillions Deaths due to Coronary heart disease India China EME
  16. 16. Model of the Stages of Epidemiologic Transition Stages of development Deaths from CVD Predominant CVD and Risk Factor Regional Examples Age of pestilence and famine 5-10 % of total deaths Rheumatic heart disease, infections, and nutritional cardiomyopathies Sub-Saharan Africa, rural India, South America Age of receding pandemics 10-35 As above hypertensive heart disease and hemorrhagic strokes China Age of degenerative and man-made diseases 35-65 All forms of strokes, ischemic heart disease at young ages, increasing obesity, and diabetes Urban India, former socialist economies, aboriginal communities Age of delayed degenerative diseases < 50 Stroke and ischemic heart disease at old age Western Europe, North America, Australia, New Zealand Age of health regression and social upheaval 35-55 Re-emergence of deaths from rheumatic heart disease, infections, increased alcoholism, and violence; increase in Russia
  17. 17. • Regression Dilution Bias • Lag Effect
  18. 18. Economic burden Cost of CAD Cost to the individual and family Cost to government of health care Cost of “HUMAN LIFE” Cost to country of lost productivity
  19. 19. • A cross-sectional study was conducted by Huffman et al Patients in Argentina, China, India, and Tanzania bear a significant burden of out-of-pocket payments, as defined by Catastrophic Health Spending and Distress Financing, following CHD hospitalization, though substantial variations exist across and within countries. • A Cross-Sectional Study of the Microeconomic Impact of Cardiovascular Disease Hospitalization in Four Low- and Middle-Income Countries
  20. 20. Descriptive Epidemiology : Distribution Patterns as per Age and Gender • National Health and Nutrition Examination Survey: 2009–2012. • Mozaffarian D et al. Circulation. 2015;131:e29-e322 • American Heart association 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 20-39 40-59 60-79 80+ 0.60% 6.30% 19.90% 32.20% 0.60% 5.60% 9.70% 18.80% PERCENTOFPOPULATION AGE IN YEARS Prevalence of coronary heart disease by age and gender
  21. 21. Descriptive Epidemiology : Distribution Patterns as per Gender • Higher rates of coronary heart disease among men compared with women (premenopausal age) • Heart disease affects women approximately 10 years later than men, possibly due to the protective effect of estrogen.A woman’s risk of a heart attack increases steeply after menopause, when her LDL-C and triglyceride levels begin to increase and her good cholesterol (HDL-C) level begins to fall. • After menopause, women’s cholesterol levels are, on average, higher than those of men of about the same age.
  22. 22. Descriptive Epidemiology : Distribution Patterns as per Ethnicity Prevalence of CVD for specific degrees of carotid atherosclerosis. The prevalence of CVD increases with increasing carotid atherosclerosis in each ethnic group.
  23. 23. • Although both Chinese and Asian Indians in the US are classified as Asian Americans, they are diametrically opposite in terms of morbidity and mortality from CAD (coronary artery disease). • Despite very high rates of smoking and high blood pressure, the Chinese have very low and the Japanese have the lowest rates of heart disease . • In sharp contrast Asian Indians have the highest rates of heart disease despite having similar or lower levels of traditional risk factors, with the exception of diabetes
  24. 24. Asian-Indian paradox • Asian Indian paradox refers to the excess burden of heart disease among Asian Indians despite having a low prevalence of traditional risk factors. Studies in the US, UK, Canada, Singapore, and other countries have shown prevalence of traditional risk factors such as smoking, obesity, hypertension, and high cholesterol levels is similar or lower in Asian Indians compared to Europids.
  25. 25. • Coronary artery disease (CAD) rates and lipoprotein levels are similar among vegetarians and non-vegetarians. This is in sharp contrast to the findings from Western vegetarians, who have a favourable lipid profile and low rates of CAD. • Although the prevalence of insulin resistance, glucose intolerance, metabolic syndrome, and diabetes are very high, these conditions do not fully explain the excess burden of premature death from CAD among Asian Indians. • Prospective studies have shown that the incidence and mortality from CAD is at least two-fold higher among Asian Indians, even when adjusted for standard risk factors including diabetes and metabolic syndrome.
  26. 26. Analytical epidemiology
  27. 27. Non Modifiable factors and Modifiable factors Non-Modifiable factors Modifiable factors Advancing Age High Blood Pressure Gender Obesity Heredity / Family history Abnormal Blood Lipids Ethnicity / Race Unhealthy Diet Tobacco use Diabetes Physical inactivity
  28. 28. Other Modifiable Risk Factors Novel Risk Factors Socio-economic Status Excess homocysteine in blood Alcohol Use Abnormal blood coagulation Mental Ill health Inflammation Psycho-social stress Lipoprotein(a) CRP Vitamin - D
  29. 29. Genetics • Recent genome wide association studies indicate that genetic factors predisposing to heart attack in patients with heart disease are distinct from those that associate with the presence of heart disease. • Having ABO blood group “O” may reduce the risk of heart attack by up to 20%. • Reilly M P, Li M, He J, et al. Identification of ADAMTS7 as a novel locus for coronary atherosclerosis and association of ABO with myocardial infarction in the presence of coronary atherosclerosis: two genome-wide association studies. Lancet. Jan 29 2011;377(9763):383-392.
  30. 30. • A study which compared 12,393 individuals with coronary artery disease (CAD) with 7383 controls (without any narrowing on angiography) , identified a new locus, ADAMTS7, to be a common genetic risk factor for heart disease, with a 19% increased risk for carriers. • Nine genome wide studies have found 14 chromosomal loci at which one or more common single nucleotide polymorphisms (SNPs) are associated with CAD or heart attack. Almost all these studies have implicated the 9p21.3 locus, considered as the most widely and consistently replicated genetic risk factor for CAD. • Reilly M P, Li M, He J, et al. Identification of ADAMTS7 as a novel locus for coronary atherosclerosis and association of ABO with myocardial infarction in the presence of coronary atherosclerosis: two genome-wide association studies. Lancet. Jan 29 2011;377(9763):383-392.
  31. 31. Blood Pressure • High blood pressure (hypertension) is one of the most important preventable causes of premature death worldwide. • Even a blood pressure at the top end of the normal range increases risk. • High BP is SBP >140 mmHg and/or DBP >90 mmHg Predictor in relation to CAD /CHD • Does the Relation of Blood Pressure to Coronary Heart Disease Risk Change With Aging? The Framingham Heart Study < 50 years of age DBP strong predictor 50-59 years of age SBP + DBP + PP (Transition state) > 60 years of age PP as best predictor
  32. 32. ROLE OF HDL-C AND LDL-C HDL-C < 40 mg/dl in men < 50 mg/dl in women LDL-C > 100 mg/dl Triglycerides >150 mg/dl BALANCE OF CAD INDEPENDENT RISK FACTOR
  33. 33. Lipoprotein (a) “The Deadly Cholesterol” • Lipoprotein (a) is a strong, putative, and causal risk factor for heart disease. It is a genetic variant of LDL. • Lp (a) is one of the strongest biological markers for premature heart disease. • Enas EA, Chacko V, Senthilkumar A, Puthumana N, Mohan V. Elevated lipoprotein(a)–a genetic risk factor for premature vascular disease in people with and without standard risk factors: a review. Dis Mon. Jan 2006;52(1):5-50.
  34. 34. Multiplicative effects of Lp(a) • Enas EA, Chacko V, Senthilkumar A, Puthumana N, Mohan V. Elevated lipoprotein(a)–a genetic risk factor for premature vascular disease in people with and without standard risk factors: a review. Dis Mon. Jan 2006;52(1):5-50. Risk outcome Elevated levels of Lp(a) present only *3 + low HDL-C *8 + high LDL-C *12-14 + high TC/ HDL-C Ratio *25 + high homocysteine *12-30 + other risk factors Can extend up to *122
  35. 35. Tobacco • Tobacco causes a fifth of cardiovascular disease worldwide. • India is the home to 12% of world’s smokers. (WHO) • In the USA, up to 62 000 people die each year from heart disease caused by passive smoking. • Quitting smoking effectively reduces cardiovascular risk to close to that of a person who has never smoked. 25 cigarettes/day – risk by 8 times High BP Risk in women who use OCP Risk of death and re- infarction after CABG Beneficial effects of physical activity Life expectancy INCREASE DECREASE EFFECT OF SMOKING TOBACCO
  36. 36. Physical inactivity • A coalescence of anthropological estimations of Homo sapiens’ phenotypes in the late Palaeolithic era 10,000 years ago, with Darwinian natural selection synergized with Neel’s idea of the so-called thrifty gene suggests that humans inherited genes that were evolved to support a physically active lifestyle. • Worldwide, physical inactivity causes about 1.9 million deaths, 20% of cardiovascular disease and 22% of coronary heart disease. • Being physically inactive increases your risk of coronary heart disease and ischaemic stroke by around 1.5 times.
  37. 37. Obesity • Abdominal girth and waist-to-hip ratio are useful indicators of obesity. • The Body Mass Index (BMI), a measure of weight in relation to height, is commonly used for classifying overweight and obesity.
  38. 38. Diabetes and CAD DIABETICS 12-40 times the rate of CAD as in non-diabetic More advanced atherosclerosis . High blood glucose is a greater risk factor for CAD and stroke than smoking poor success and survival rates following angioplasty and bypass surgery 2 Times more mortality rate
  39. 39. Socio-economic status In developing countries, higher socioeconomic class has been associated with a higher prevalence of CAD. • Coronary artery disease in the developing world - Karen Okrainec, MSc, a Devi K. Banerjee, MD, b and Mark J. Eisenberg, MD, MPHc Montreal, Quebec, Canada 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% High SES Low SES 61% 30% 20% 9% Prevalence of CAD in Urban Population as per SES status Males Females
  40. 40. Psychological • Contrary to common belief, type A personality is not associated with an excess of coronary artery disease (CAD). Moreover, the prognosis of CAD among type A persons is better than in type B patients. • Type “D” personality: defined as the joint tendency towards negative affectivity and social inhibition. It is associated with coronary heart disease. [??] • Enas EA, Garg A, Davidson MA, Nair VM, Huet BA, Yusuf S. Coronary heart disease and its risk factors in first-generation immigrant Asian Indians to the United States of America. Indian Heart J. 1996;48(4):343- 353.
  41. 41. hs-CRP • Acute phase reactant ( inflammatory marker) • CRP level has been proposed as biomarker for CVD and CAD risk prediction and as a selection marker for initiating statin treatment. • More than 70% of obese women and more than 50% of obese men having elevated levels of CRP • Smokers have 38% higher CRP levels than Non-smokers • Ridker PM, Wilson PW, Grundy SM. Should C-reactive protein be added to metabolic syndrome and to assessment of global cardiovascular risk? Circulation. Jun 15 2004;109(23):2818-2825. • Jeemon P, Prabhakaran D, Ramakrishnan L, et al. Association of high sensitive C-reactive protein (hsCRP) with established cardiovascular risk factors in the Indian population. Nutrition & metabolism. Mar 28 2011;8(1):19.
  42. 42. Vitamin-D • Low vitamin D levels are highly associated with endothelial dysfunction, atherosclerosis, heart attack, heart failure, stroke as well as silent and symptomatic CAD (coronary artery disease), CVD (cardiovascular disease) and death. • Vitamin D concentrations are inversely associated with insulin resistance (IR) and metabolic syndrome (MS). • Anagnostis P, Athyros VG, Adamidou F, Florentin M, Karagiannis A. Vitamin D and cardiovascular disease: a novel agent for reducing cardiovascular risk? Curr Vasc Pharmacol. Sep 2010;8(5):720-730 • Wang TJ, Pencina MJ, Booth SL, et al. Vitamin D deficiency and risk of cardiovascular disease. Circulation. Jan 29 2008;117(4):503-511
  43. 43. Risk assessment scores • Framingham risk score • Lifetime risk • Risk estimation by disease status • SCORE (Systematic COronary Risk Evaluation) • German PROCAM Risk score • Pooled cohort risk score
  44. 44. Interventional epidemiology
  45. 45. Primordial prevention prevention of the risk factors for CVD, such as efforts aimed to prevent hypertension, obesity, or dyslipidaemia Primary prevention modification of these and other known risk factors, is aimed at preventing the clinical manifestations of CVD, such as myocardial infarction and stroke Secondary prevention focuses on those who already have manifestations of disease, but where aggressive control of risk factors can have a major impact in preventing recurrences of disease. Tertiary prevention use of expensive coronary interventional procedures such as coronary angioplasty, stent, bypass surgery, pacemakers, defibrillators, and left ventricular assist devices (LVAD).
  46. 46. ABCDE Approach • Oxford Textbook of Global Public Health Aspirin / Anti-platelet therapy Blood pressure monitoring Cholesterol & Dyslipidaemia management Diet and Nutrition Exercise and Physical Activity A B C D E
  47. 47. Three Pronged Approach Individual Policies/ legislati on Community/ population
  48. 48. Individual level  Take moderate physical activity for a total of 30 minutes on most days of the week.  Avoid tobacco use and exposure to environmental smoke; make plans to quit if you already smoke.  Diet: fruits, vegetables and avoid saturated fats and calorie- dense meals.  Maintain a normal body weight.  Reduce stress at home and work.
  49. 49. Population / community level • Significant health gains in cardiovascular health can be made within short time spans, through public health and treatment interventions that have an impact on large segments of the population. • Population based observational studies in Finland, Norway, Mauritius, Poland and the US reported substantial reduction in cholesterol levels and coronary artery disease (CAD) mortality, following the introduction of fiscal policies which reduced animal fat and increased vegetable fat consumption
  50. 50. FINLAND North Karelia Project By 2005, CAD mortality in men and women had declined by 80%. POLAND Mortality due to CAD fell 40% from 1990 to 2002 (decrease of 3% per year), reversing the previous steady rises (increase of 6% per year) MAURITIUS Total cholesterol levels in the population fell by 32 mg/dl between 1987 and 1992.This followed an intervention by the government in 1987, to change the composition of the commonly used cooking oil from mostly palm oil (high in saturated fatty acids) to soya bean oil exclusively NORWAY Between 1975 and 1993 dietary saturated fat consumption reduced by 18% of energy intake, leading to a reduction in blood cholesterol of 10% in the general population and decreasing CAD mortality by 50% among middle-aged men
  51. 51. Policies and Legislations • Global Action Plan for the Prevention and Control of NCDs 2013-2020 • National Programme For Prevention And Control Of Cancer, Diabetes, CVD And Stroke (NPCDCS)
  52. 52. Recommendations to address the CAD epidemic in the Indian subcontinent
  53. 53. Suggested policy interventions • Establishment of a national regulatory agency to enforce already existing tobacco control legislation (e.g., the Tobacco Control Act and the World Health Organization’s Framework Convention on Tobacco Control). • High rates of use of smoked beedies and of smokeless tobacco (chewing tobacco and paan). • Promote healthy dietary patterns and physical activity in schools and workplaces. • Identification of cultural norms that might hinder CHD prevention efforts
  54. 54. Suggested capacity building measures • Development of research infrastructure and training of clinical researchers. • Establishment of high-quality national surveillance programmes • Assessment of the knowledge of the CHD burden
  55. 55. Suggested research initiatives • Generation of reliable statistics on prevalence and incidence of CAD and its risk factors and CAD-related mortality through the initiation of large cohort studies and trial registries. • Randomized controlled clinical trials based in South Asian countries to answer research questions of high relevance to the Indian subcontinent (e.g., effectiveness of the polypill in CHD prevention, homocysteine lowering in subjects with vascular disease). • Studies documenting childhood risk factors, such as obesity, in both urban and rural settings. • Large registries and case-control studies to document the burden of CHD and its determinants in the Indian subcontinent.
  56. 56. Prevention Paradox Population at Low Risk / Moderate Risk High Risk Population Majority of cases Minority of cases
  57. 57. Barriers to prevention • The physicians themselves need to be educated about the importance of prevention and the patients should be willing to accept and act on the advice of the physicians. • As urbanization and globalization bring beneficial changes to LMIC countries, it also increases the risk factors for CHD and promotes unhealthy practices. • The cost of preventive care is rarely reimbursed by the government or the insurance companies like that of the curative care. • Enas EA, Singh V, Gupta R, Patel R, et al. Recommendations of the Second Indo-US Health Summit for the prevention and control of cardiovascular disease among Asian Indians. Indian heart journal. 2009;61:265-74. • Rankin J, Bhopal R. Understanding of heart disease and diabetes in a South Asian community: cross-sectional study testing the ‘snowball’ sample method. Public Health. 2001;115(4):253-260.
  58. 58. Barriers…. • Reducing excess risk in South Asians requires multilevel, positive, mainstream and targeted measures using multiple approaches. These should address awareness, access, services, discrimination, cultural sensitivity and biologic factors, modified for different countries, situations and contexts. • The Indo-US Healthcare Summit provides comprehensive, detailed and practical recommendations, advocating primordial, primary, and secondary prevention by government, medical communities, the public, industry and the media. • Policy, grass-roots change, and community building should encourage healthy living at all ages, and remove barriers. Population screening, awareness and change should start early and tap community strengths.
  59. 59. Future • Predictions are by their nature speculative. Nevertheless, this much is certain: the global epidemic of cardiovascular disease is not only increasing, but also shifting from developed to developing nations. • No matter what advances there are in high-technology medicine, the fundamental message is that any major reduction in deaths and disability from CAD will come from prevention, not cure. This must involve robust reduction of risk factor
  60. 60. • “Live sensibly - among a thousand people, only one dies a natural death; the rest succumb to irrational modes of living.” - Maimonides
  61. 61. Thank You
  62. 62. Objectives of NPCDCS • 1) Prevent and control common NCDs through behaviour and life style changes, • 2) Provide early diagnosis and management of common NCDs, • 3) Build capacity at various levels of health care for prevention, diagnosis and treatment • of common NCDs, • 4) Train human resource within the public health setup viz doctors, paramedics and • nursing staff to cope with the increasing burden of NCDs, and • 5) Establish and develop capacity for palliative & rehabilitative care.
  63. 63. Strategies • The Strategies to achieve above objectives are as follows: • 1) Prevention through behaviour change • 2) Early Diagnosis • 3) Treatment • 4) Capacity building of human resource • 5) Surveillance, Monitoring & Evaluation

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