Cardiovascular Epidemiology Part II

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					  ____________________________________________________________

  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
____________________________________________________________

    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.
                             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
          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)
                             30                                                                                    27
Estimated 10-Year Rate (%)
                             25                                                                             22.4
                                                        Men     W omen                               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
                                                    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

                                                                          *BP in millimeters of mercury (mmHg)
                                   Estimated 10-year stroke risk in 55-year-old adults
                                   according to levels of various risk factors (FHS).
                                   Source: Wolf et al., Stroke.1991;22:312-318.
  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
Risk imposed by a strong family
history of heart attacks varies widely
depending on the burden of
modifiable risk factors




                     Multivariable Risk
             9

Doubts about
cholesterol as
 late as 1989
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.
                                            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.
_______________________________________________________________________________

       Lifetime Risk of CHD Increases
       with Serum Cholesterol
    ___________________________________________________________________________
              60
                                                Cholesterol
              50                                 <200 mg
                                                 200-239 mg
                                                 >240 mg
              40                 57
   Percent




              30
                           44
              20      34
                                                       33
              10                                29

                                           19
               0
                           Men                   Women

             Framingham Study: Subjects age 40 years
             DM Lloyd-Jones et al Arch Intern Med 2003; 1966-1972
                        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.
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.
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.
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.
   ________________________________________________________



   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.”
_______________________________________________________________
 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, Diabetes
4%                       4.4                          and smoking *P<.001
                   2.8
2%
           1.9
0%
           Women                       Men

Framingham Study: Subjects Ages 35-90 yrs.
                        90.0                                                                             83.8
Percent of Population   80.0                                                               73.9
                                                                                                  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.
                        80      74.6   75.3
Percent of Population                                         68.4
                        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.
Percent of Population   50
                                                          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.
Percent of Population   90
                        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.
_______________________________________________________________




     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”
_______________________________________________________________

     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
____________________________________________________________

 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.”
   ___________________________________________________________
                Circulation 1960; vol. 23
CHD Risk by Cigarette Smoking.
Filter Vs. Non-filter. Framingham
Study. Men <55 Yrs.
14-yr. Rate/1000

 250
                   206 210               Non-Smoker
 200                                     Reg. Cig. Smoker
                                         Filter Cig. Smoker
 150                                     210
          119
                                   112
 100
                              59
   50

     0
         Total CHD           Myocardial
                             Infarction
                        40                            37.3
Percent of Population   35                                                                33.4
                        30
                             24.1 23.9
                        25                                        20.4 20.2
                                         18.9 17.8
                        20                                                    15
                        15                                                         11.3
                        10
                         5
                         0
                                         Men                               Women

           NH White           NH Black     Hispanic     Asian   American Indian or Alaska Native


             Prevalence of current smoking for Adults age 18
             and older by race/ethnicity and sex (NHIS:2004).
             Source: MMWR. 2004;54:1121-24. NH – non-Hispanic.
                        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.
     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”
 ______________________________________________________________
 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
                        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.
                           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.
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.
  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.”
                        Risk Factor Sum and Obesity
                                       Framingham Study
                                    (1971-74) and (1989-93)
                    3

                  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
                        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.
                        20                              18.7
Percent of Population   18                                                                     16.3
                        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.
                        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.
Percent of Population
                             50                                                                                                                              45.7              44.8
                                                                                 37.5                                                                                                  39.6                           36.3
                             40                             34.2                             32.5                      34.4                                            33.9                   31.5                           31.8
                                         26.4                           27.0                                                          28.3
                             30                                                                  25.0                            23.8                                                             24.0
                                                                                                                                         21.6
                                                   18.4                                                       20.4
                             20
                             10
                             0
                                               e                  e                    e                e                    e                    e                e               e                e
                                             al                 al                   al               al                   al                  al                al             al                al
                                                            M                    M                                     M                   m                 m                 m              m                       ...
                                    te
                                         M
                                                        k                    c                      rM             e                     Fe                Fe               Fe              Fe                    e
                                 hi                  ac                   ni                    e                iv                                                                       r                  at
                                                                                                                                                                                                                iv
                                                   Bl                    a                    nd              at                    te              ac
                                                                                                                                                       k
                                                                                                                                                                     ni
                                                                                                                                                                        c             e
                             W                                         sp                  sla               N                   hi                                                 nd                      N
                                              NH                  Hi                   I                 a                                        Bl              sp
                                                                                                                                                                    a                                   a
                        NH                                                        ic                  sk
                                                                                                                             W
                                                                                                                                                             Hi                  sla           sk
                                                                              cif                   la                 NH                  NH                                 ic
                                                                                                                                                                                 I
                                                                                                                                                                                            Ala
                                                                            Pa                    /A                                                                      cif             n/
                                                                        /                      an                                                                        a              ia
                                                                    i an                    ndi                                                                        /P             nd
                                                                  As                   .I                                                                            an            .I
                                                                                                                                                                  si
                                                                                 Am                                                                              A              Am

                                                                                                                             1994              2004


                              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.
                              NH – non-Hispanic.
                                     46.9
                        50
Percent of Population                                           NH White     NH Black      Hispanic
                        45                            39
                                             38.2
                        40
                        35                                                 30.2
                        30                                                                   26.5
                        25                                                         21.3
                        20
                        15
                        10
                         5
                         0
                                             Male                                 Female
                                                       Sex and Race/Ethnicity

                        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.
                          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.

				
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