CVD Epidemiology

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					Cardiovascular Epidemiology:
Definitions
Historical Perspectives and Assessing
Risk of CVD
Recent trends and population
differences in CHD and CHD risk
factors
                     Deaths in Thousands
   500                             461
          410
   400

   300        285                        265
                                                              Males
   200                                                        Females

   100              70   59                    64
                              35                    47 38
      0
          A     B   C    D    E    A     B     D    F   E

   A Total CVD                 D Chronic Lower Respiratory Diseases
   B Cancer                    E Diabetes Mellitus
   C Accidents                 F Alzheimer’s Disease
Leading causes of death for all males and females
(United States: 2004). Source: NCHS and NHLBI.
                                52%




  13%
                                                  17%
        .4%         4%    6%    7%
              .5%
     Coronary Heart Disease
                                 Stroke
     Heart Failure
                                 High Blood Pressure
     Diseases of the Arteries
     Defects                     Congenital Cardiovascular
     Rheumatic Fever/            Other
     Rheumatic Heart Disease

Percentage breakdown of deaths from cardiovascular diseases
(United States:2004)
Source: NCHS and NHLBI.
                       1 000
                        900                                                                         872
 Deaths in Thousands




                        800
                        700
                        600                                                                               555
                        500
                        400                                                              325
                        300                                                      267
                        200                                                        165
                                                                       130 139                 80
                                                               78 96
                        100                  16 15   46 49
                               5 3   4 4
                          0
                               <25   25-34   35-44   45-54     55-64   65-74     75-84   85+        Total

                                                             CVD   Cancer



Cardiovascular disease deaths vs. cancer deaths by age
(United States: 2004). Source: NCHS and NHLBI.
Development of Atherosclerotic
Plaques
                           Fatty streak
      Normal


                                                           Lipid-rich plaque



                                          Foam cells

                                             Fibrous cap




                                                              Lipid core
                  Thrombus




 Ross R. Nature. 1993;362:801-809.
Atherosclerotic Plaque Rupture and
Thrombus Formation

                                                      Growth of thrombus
 Intraluminal thrombus




   Blood Flow




 Intraplaque thrombus                                   Lipid pool

 Adapted from Weissberg PL. Eur Heart J Supplements
 1999:1:T13–18
  PDAY: Percentage of Right Coronary Artery
  Intimal Surface Affected With Early Atherosclerosis

           30                                  Raised lesions 30
                          Men                  Fatty streaks
                                                                              Women

           20                                                     20


           10                                                     10


            0                                                     0
Intimal           15-19 20-24 25-29 30-34                              15-19 20-24 25-29 30-34
surface    30             White                                                 White
                                                                  30
  (%)
           20                                                     20

           10                                                     10


            0                                                      0
                 15-19 20-24 25-29 30-34                               15-1920-2425-2930-34
                         Black                                                 Black

                                                  Age (y)
PDAY= Pathobiological Determinants of Atherosclerosis in Youth.
Strong JP, et al. JAMA. 1999;281:727-735.
Coronary Remodeling

        Progression
                                                                 Expansion
                                    Compensatory expansion       overcome:
                                    maintains constant lumen   lumen narrows




       Normal                       Minimal         Moderate      Severe
       vessel                        CAD             CAD           CAD
(Adapted from Glagov et al.)

Glagov et al, N Engl J Med, 1987.
Most Myocardial Infarctions Are Caused
by Low-Grade Stenoses




Pooled data from 4 studies: Ambrose et al, 1988; Little et al, 1988; Nobuyoshi et al, 1991; and Giroud et al,
1992.
(Adapted from Falk et al.)
Falk E et al, Circulation, 1995.
Vulnerable Versus Stable
Atherosclerotic Plaques
                                           Vulnerable Plaque
             Lumen             Lipid        • Thin fibrous cap
          Fibrous Cap
                               Core         • Inflammatory cell infiltrates:
                                              proteolytic activity
                                            • Lipid-rich plaque

                                           Stable Plaque
                                            • Thick fibrous cap
          Lumen             Lipid           • Smooth muscle cells:
                            Core
                                              more extracellular matrix
          Fibrous Cap
                                            • Lipid-poor plaque


Libby P. Circulation. 1995;91:2844-2850.
Correlation of CT angiography of the
coronary arteries with intravascular
ultrasound illustrates the ability of MDCT
to demonstrate calcified and non-calcified
coronary plaques (Becker et al., Eur J
Radiol 2000)                                 Non-calcified, soft, lipid-rich plaque in
                                             left anterior descending artery (arrow)
                                             (Somatom Sensation 4, 120 ml Imeron
                                             400). The plaque was confirmed by
                                             intravascular ultrasound (Kopp et al.,
                                             Radiology 2004)
Features of a Ruptured
Atherosclerotic Plaque


                                                   • Eccentric, lipid-rich
                                                   • Fragile fibrous cap
                                                   • Prior luminal
                                                     obstruction < 50%
                                                   • Visible rupture
                                                     and thrombus




Constantinides P. Am J Cardiol. 1990;66:37G-40G.
Clinical Manifestations
of Atherosclerosis

      • Coronary heart disease
           –   Stable angina, acute myocardial infarction, sudden
               death, unstable angina

      • Cerebrovascular disease
           –   Stroke, TIAs

      • Peripheral arterial disease
           –   Intermittent claudication, increased risk of death
               from heart attack and stroke




American Heart Association, 2000.
Definitions
• CARDIOVASCULAR DISEASE or CVD
  includes CORONARY ARTERY DISEASE
  and other cardiac conditions (congenital,
  arrhythmias, and congestive heart failure)

• CORONARY ARTERY DISEASE (CAD) or
  CORONARY HEART DISEASE (CHD)
  (often broadly referred to as ISCHEMIC
  HEART DISEASE (IHD): primarily
  myocardial infarction and sudden
  coronary death, broader definition may
  include angina pectoris, atherosclerosis,
  positive angiogram, revascularization, and
  myocardial infarction
Definitions (cont.)
• REVASCULARIZATION includes coronary
  artery bypass graft (CABG), percutaneous
  transluminal coronary angioplasty (PTCA),
  stent, and atherectomy
• CEREBROVASCULAR DISEASE includes
  stroke (ischemic or hemorrhagic) and
  transient ischemic attack (TIA)
• PERIPHERAL VASCULAR DISEASE
  includes carotid artery disease and
  intermittent claudication
• SURROGATE MEASURES include: carotid
  intimal medial thickness (IMT), coronary
  calcium, angiographic stenosis, brachial
  ultrasound flow mediated dilatation (FMD)
                                                                                      92.0
                              100.0
      Percent of Population

                                                                              83.0
                               80.0                               71.3 75.1

                               60.0
                                                   39.1 39.5
                               40.0

                               20.0   14.8
                                             9.4

                                0.0
                                       20-39        40-59          60-79             80+

                                                        Males   Females

Prevalence of cardiovascular diseases in adults age 20 and older
by age and sex (NHANES: 1999-2004). Source: NCHS and NHLBI.
These data include coronary heart disease, heart failure, stroke and hypertension.
                        35.0
                                                                      32.7
Percent of Population



                        30.0
                        25.0                            22.8
                                                                                   21.6
                        20.0
                                                               15.4
                        15.0
                        10.0             7.8
                                               5.5
                         5.0
                               0.6 0.6
                         0.0
                                20-39     40-59          60-79               80+

                                                Men   Women

      Prevalence of coronary heart disease by age and sex
      (NHANES :1999-2004). Source: NCHS and NHLBI.
   Annual Number of Americans Having
   Diagnosed Heart Attack by Age and Sex
   ARIC: 1987-2000


                            500,000
New and Recurrent Attacks




                                                                           410,000
                            400,000                                                  372,000


                            300,000                     250,000                                Men

                            200,000                                                            Women

                                                                  88,000
                            100,000
                                      34,000
                                               10,000
                                 0
                                         29-44             45-64               65+
                                                           Ages



   Source: Extrapolated from rates in the NHLBI’s ARIC surveillance study,
   1987-2000. These data don’t include silent MIs.
Annual Rate of First Heart Attacks
by Age, Sex and Race
ARIC: 1987-2000


                       14
                       12
   Per 1,000 Persons




                       10                                          White Men
                       8                                           Black Men
                       6                                           White Women
                       4                                           Black Women

                       2
                       0
                            35-44   45-54          55-64   65-74
                                            Ages




Source: NHLBI’s ARIC surveillance study, 1987-2000.
                         16
                                                                 14.8
 Percent of Population


                         14                                              12.4
                         12
                         10
                         8                             6.5 6.2
                         6
                         4                    2.3
                         2              1.2
                              0.5 0.5
                         0
                               20-39     40-59          60-79           80+

                                               Men   Women


Prevalence of stroke by age and sex (NHANES: 1999-2004).
Source: NCHS and NHLBI.
                        14
                                                                         12.4
                                                                  11.6
Percent of Population



                        12
                        10
                         8                            7.2

                         6                                  5.2

                         4
                                         2   1.5
                         2
                             0.3   0.2
                         0
                              20-39      40-59         60-79        80+

                                              Men   Women


Prevalence of heart failure by age and sex
(NHANES: 1999-2004). Source: NCHS and NHLBI.
                          700
Discharges in Thousands




                          600
                                        Male   Female
                          500
                          400
                          300
                          200
                          100
                           0
                                79 80     85            90           95   00   04

                                                             Years



  Hospital discharges for heart failure by sex
  (United States: 1979-2004). Source: NHDS, NCHS and NHLBI.
  Note: Hospital discharges include people discharged alive, dead and
  status unknown..
                      520
                      500
Deaths in Thousands




                      480
                      460
                      440
                      420
                      400
                        0
                      380
                            79 80   85           90             95   00   04

                                                      Years

                                         Males        Females
Source: NHLBI 2002 Chart Book on Cardiovascular, Lung, and Blood Diseases
  ____________________________________________________________

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
                    mm Hg = millimeters of mercury
                    mg/dL = milligrams per deciliter of blood

Source: Circulation 1998;97:1837-1847.
                             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)
Estimated 10-Year Rate (%)   30                                                                                  27
                             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                   57              <200 mg
                                                  200-239 mg
                                                  >240 mg
             40
                            44
   Percent




             30        34
                                                               33
             20                                     29

                                            19
             10

              0
                            Men                   Women
                  Framingham Study: Subjects age 40 years
                  DM Lloyd-Jones et al Arch Intern Med 2003; 1966-1972
                         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
                        80.0                                                               73.9
Percent of Population



                                                                                                  69.5
                        70.0                                                        63.6
                        60.0                                                 55.4
                                                                      49.1
                        50.0
                                                          37.5 37.4
                        40.0
                        30.0                23.2
                                                   18.3
                        20.0   11.2
                        10.0          6.4
                         0.0
                                20-34         35-44          45-54      55-64         65-74          75+

                                                               Men    Women


Prevalence of high blood pressure in Adults by age and sex
(NHANES: 1999-2004). Source: NCHS and NHLBI.
                        80      74.6   75.3
                                                              68.4
Percent of Population


                        70                             62.5
                        60   52.3
                        50                                                        39.8
                        40                      35.8                                      34.3
                        30                                                 24.6
                        20
                        10
                         0
                              Awareness           Treatment                  Controlled

                                              20-39     40-59        60+



Extent of awareness, treatment and control of high blood
pressure by age (NHANES : 1999-2004.) Source: NCHS and NHLBI.
                        50
Percent of Population


                                                          37.5 39.0   38.2   41.4
                        40
                                     28.5          28.0                          26.9 26.2           27.0
                        30    25.6                                                            25.0
                                            22.9
                        20

                        10
                         0
                             NH White-      NH White-      NH Black   NH Black      Mexican    Mexican
                             Only Men         Only        or AA Men    or AA         Men       Women
                                             Women                     Women

                                                            1988-94    1999-04



     Age-adjusted prevalence trends for high blood pressure in
     Adults age 20 and older by race/ethnicity, sex and survey
     (NHANES: 1988-94 and 1999-2004). Source: NCHS and NHLBI.
                        90
Percent of Population


                        80   72.9    76.9
                                                                66.9
                        70                  62.4         63.4
                        60
                                                                       49.1
                        50
                                                                                37.2
                        40                                                             33.6
                        30                                                                    25.1
                        20
                        10
                         0
                               Awareness                   Treatment                Controlled

                                    NH Whites      NH Blacks    Mexican Americans


Extent of Awareness, Treatment and Control of High
Blood Pressure by Race/Ethnicity
(NHANES: 1999-2004).
Source: NCHS and NHLBI.
_______________________________________________________________




  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.”
CHD Risk by Cigarette Smoking. Filter
Vs. Non-filter. Framingham Study. Men
<55 Yrs.
   14-yr. Rate/1000

       250
                                                Non-Smoker
       200                                      Reg. Cig. Smoker
                       206
                             210
                                                Filter Cig. Smoker
       150

                                                210
       100       119
                                          112



         50                          59




           0
               Total CHD           Myocardial
                                   Infarction
                         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
                      3                           (1971-74) and (1989-93)

                   2.4            (1971)                  (1989)
Risk Factor Sum




                            Risk factors accumulate with weight gain
                   1.8

                   1.2

                   0.6

                     0
                             Q1             Q2           Q3           Q4          Q5           Overall
                            Thin                                                 Obese
                  Risk variables include bottom quintile for HDL-C and top
                  quintiles for cholesterol, SBP, triglycerides and glucose   Wilson PWF, & Kannel WB
                                                                              Nutr Clin Care 1999; 1:44-50
                          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
                         18                                                                 16.3
 Percent of Population




                         16
                         14
                                             11.6                                      11
                         12
                         10
                          8         6.6                                      6.4
                          6   4.3
                                                                     3.6
                          4
                          2
                          0
                                          6-11                                 12-19

                                           1971-74    1976-80   1988-94    2001-2004


Trends in prevalence of overweight among U.S. children and
adolescents by age and survey
(NHANES, 1971-74, 1976-80, 1988-94 and 2001-2004).
Source: Health, United States, 2006, unpublished data. NCHS.
                        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
                                                       ck                  ic                   e   rM               e                     Fe                Fe                Fe                         Fe                  iv
                                                                                                                                                                                                                                e
                                 hi                                      an                                        iv
                                                     la                                       nd                at                    te                ck              ic                          e   r                  at
                             W                     B                   sp                  sla                 N                   hi                 la              an                          nd                      N
                        NH                    NH                  Hi                   I                  ka                   W                    B               sp                         sla             sk
                                                                                                                                                                                                                      a
                                                                                  ic                    as               NH                  NH                Hi                          I
                                                                              cif                   /A
                                                                                                      l
                                                                                                                                                                                 if   ic                    Ala
                                                                        /   Pa                 an                                                                             ac                          n/
                                                                                             di                                                                                                         ia
                                                                    i an                                                                                                  n/
                                                                                                                                                                             P                        nd
                                                                  As                   .   In                                                                           ia                      .   I
                                                                                Am                                                                                 As                  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
                                                    NH White     NH Black      Hispanic
Percent of Population


                        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.
International Comparisons in
CVD Morbidity and Mortality
• CVD accounts for 25-45% of deaths
  among different countries
• CVD death rates (per 100,000)
  range from 1310 in Russia to 201 in
  Japan (6.5 fold difference) in men
  and from 581 in Russia to 84 in
  France (7-fold difference)
• USA ranks 16th for both men (413)
  and women (201)
Secular Trends in CHD and
Stroke Mortality
• From 1985-1992, greatest annual
  decline (6-7%) in CHD seen in Israel
  among men and France among
  women, USA intermediate (4%),
  increases in Poland and Romania.
• Stroke death rates declined most in
  Australia, Italy, and France (8-9%),
  USA about 3%.
Age-Adjusted Death Rates for Coronary Heart Disease by Country and Sex,
                            Ages 35-74, 1999




•Age-Adjusted to European Standard
•Data for 1999 unless noted
Source: NHLBI 2002 Chart Book on Cardiovascular, Lung, and Blood Diseases
Age-Adjusted Death Rates for Stroke by Country and Sex, Ages 35-74, 1999




    •Age-Adjusted to European Standard
    •Data for 1999 unless noted
    Source: NHLBI 2002 Chart Book on Cardiovascular, Lung, and Blood Diseases
Change in Age-Adjusted Death Rates for Coronary Heart Disease by Country and
                         Sex, Ages 35-74, 1990-1999




                                               Men




                                              Women




      •Age-Adjusted to European Standard
      •Latest data year note in parentheses
Change in Age-Adjusted Death Rates for Stroke by Country and Sex, Ages 35-74,
                                1990-1999




                                                                              Men




                                                                               Women




  •Age-Adjusted to European Standard
  •Latest data year note in parentheses
  Source: NHLBI 2002 Chart Book on Cardiovascular, Lung, and Blood Diseases
Migrant Studies

• Ni-Hon-San Study showed
  Japanese living in Japan to have
  the lowest cholesterol levels and
  lowest rates of CHD, those living in
  Hawaii to have intermediate rates
  for both, and those living in San
  Francisco to have the highest
  cholesterol levels and CHD
  incidence
 Approaches to Primary and
 Secondary Prevention of
 CVD
• Primary prevention involves prevention
  of onset of disease in persons without
  symptoms.
• Primordial prevention involves the
  prevention of risk factors causative o
  the disease, thereby reducing the
  likelihood of development of the
  disease.
• Secondary prevention refers to the
  prevention of death or recurrence of
  disease in those who are already
  symptomatic
Risk Factor Concepts in
Primary Prevention
• Nonmodifiable risk factors include age,
  sexc, race, and family history of CVD,
  which can identify high-risk populations
• Behavioral risk factors include sedentary
  lifestyle, unhealthful diet, heavy alcohol
  or cigarette consumption.
• Physiological risk factors include
  hypertension, obesity, lipid problems,
  and diabetes, which may be a
  consequence of behavioral risk factors.
 Population vs. High-Risk
 Approach
• Risk factors, such as cholesterol or blood
  pressure, have a wide bell-shaped distribution,
  often with a “tail” of high values.
• The “high-risk approach” involves
  identification and intensive treatment of those
  at the high end of the “tail”, often at greatest
  risk of CVD, reducing levels to “normal”.
• But most cases of CVD do not occur among the
  highest levels of a given risk factor, and in fact,
  occur among those in the “average” risk group.
• Significant reduction in the population burden
  of CVD can occur only from a “population
  approach” shifting the entire population
  distribution to lower levels.
Pyramid of Risk
   (Werner et al. Canadian Journal of
   Cardiology 1998; 14(Suppl) B:3B-10B)
Expected Shifts in Cholesterol Distribution
from High-Risk, Population, and
Combined Approaches
   Population and Community-
   Wide CVD Risk Reduction
   Approaches
• Populations with high rates of CVD are those with
  Western lifestyles of high-fat diets, physical
  inactivity, and tobacco use.
• Targets of a population-wide approach must be
  these behaviors causative of the physiologic risk
  factors or directly causative of CVD.
• Requires public health services such as
  surveillance (e.g.,BFRSS), education (AHA,
  NCEP), organizational partnerships (Singapore
  Declaration), and legislation/policy (Anti-Tobacco
  policies)
• Activities in a variety of community settings:
  schools, worksites, churches, healthcare
  facilities, entire communities
A conceptual framework for public
health practice in CVD prevention.
(From Pearson et al., J Public Health. 2001; 29:69 –78)
Communitywide CVD
Prevention Programs
• Stanford 3-Community Study (1972-75)
  showed mass media vs. no intervention in
  high-risk residents to result in 23% reduction
  in CHD risk score
• North Karelia (1972-) showed public education
  campaign to reduce smoking, fat
  consumption, blood pressure, and cholesterol
• Stanford 5-City Project (1980-86) showed
  reductions in smoking, cholesterol, BP, and
  CHD risk
• Minnesota Heart Health Program (1980-88)
  showed some increases in physical activity
  and in women reductions in smoking
Materials Developed for US
Community Intervention
Trials
•   Mass media, brochures and direct mail
•   Events and contests
•   Screenings
•   Group and direct education
•   School programs and worksite
    interventions
•   Physician and medical setting programs
•   Grocery store and restaurant projects
•   Church interventions
•   Policies
Individual and High-Risk
Approaches
• Primary Prevention Guidelines (1995) and
  Secondary Prevention Guidelines (Revised 2001)
  released by the American Heart Association
  provide advice regarding risk factor assessment,
  lifestyle modification, and pharmacologic
  interventions for specific risk factors
• Barriers exist in the community and healthcare
  setting that prevent efficient risk reduction
• Surveys of CVD prevention-related services show
  disappointing results regarding cholesterol-
  lowering therapy, smoking cessation, and other
  measures of risk reduction
• Examination:
                    Presentation
   – Height: 6 ft 2 in
   – Weight: 220 lb (BMI 28
     kg/m2)
   – Waist circumference: 41
     in
   – BP: 150/88 mm Hg
   – P: 64 bpm
   – RR: 12 breaths/min
• Cardiopulmonary exam:
  normal
• Laboratory results:
   –   TC:    220 mg/dL
   –   HDL-C: 36 mg/dL
   –   LDL-C: 140 mg/dL
   –   TG:    220 mg/dL
   –   FBS: 120 mg/dL
Risk Assessment
Count major risk factors
• For patients with multiple (2+) risk
  factors
  – Perform 10-year risk assessment
• For patients with 0–1 risk factor
  – 10 year risk assessment not required
  – Most patients have 10-year risk <10%
    ATP III Assessment of CHD Risk
  For persons without known CHD, other forms of
    atherosclerotic disease, or diabetes:
  • Count the number of risk factors:
        – Cigarette smoking
        – Hypertension (BP 140/90 mmHg or on
          antihypertensive medication)
        – Low HDL cholesterol (<40 mg/dL)†
        – Family history of premature CHD
                CHD in male first degree relative <55 years
                CHD in female first degree relative <65 years
        – Age (men 45 years; women 55 years)

  • Use Framingham scoring for persons with 2
       risk factors* (or with metabolic syndrome) to
       determine the absolute 10-year CHD risk.
       (downloadable risk algorithms at
       www.nhlbi.nih.gov)
Expert Panel on Detection, Evaluation, and Treatment of          © 2001, Professional Postgraduate Services®
High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.                    www.lipidhealth.org
ATP III Framingham Risk Scoring


 Step 1: Age
            Assessing CHD Risk in Men
    Years          Points              Step 4: Systolic Blood Pressure                              Step 6: Adding Up the Points
     20-34             -9               Systolic BP         Points       Points                      Age
     35-39             -4                (mm Hg)        if Untreated if Treated                      Total cholesterol
     40-44              0                  <120               0              0                       HDL-cholesterol
     45-49              3                 120-129             0              1                       Systolic blood pressure
     50-54              6                 130-139             1              2
                                                                                                     Smoking status
     55-59              8                 140-159             1              2
                                                                                                     Point total
     60-64            10                   160               2              3
     65-69            11
     70-74            12                                                                Step 7: CHD Risk
     75-79            13                                                           Point Total 10-Year Risk         Point Total 10-Year
                                                                                   Risk
 Step 2: Total Cholesterol                                                              <0         <1%                     11          8%
                                                                                         0          1%                     12         10%
        TC     Points at       Points at    Points at      Points
                                                                                         1          1%                     13         12%
 at Points at
     (mg/dL)   Age 20-39      Age 40-49 Age 50-59 Age 60-69 Age                          2          1%                     14         16%
 70-79                                                                                   3          1%                     15         20%
       <160        0               0            0               0           0            4          1%                     16         25%
      160-199      4               3            2               1           0            5          2%                    17        30%
      200-239      7               5            3               1           0            6          2%
      240-279      9               6            4               2           1            7          3%
 Step 3: HDL-Cholesterol
       280       11               8            5               3           1            8          4%
     HDL-C                                                                               9          5%
    (mg/dL)          Points      Step 5: Smoking Status
                                                                                        10          6%
      60              -1
                                                    Points at       Points at   Points at     Points
     50-59              0          at               Points at
     40-49              1                           Age 20-39       Age 40-49 Age 50-59 Age 60-69 Age
                                   70-79
      <40               2
                                   Nonsmoker         0                  0           0           0          0
 Note: Risk estimates were derivedfrom the experience8of
                                   Smoker               the Framingham Heart Study,
                                                                  5          3                  1          1
 a predominantly Caucasian population in Massachusetts, USA.

 Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults.             © 2001, Professional Postgraduate Services®
                                                                                                                     www.lipidhealth.org
 JAMA. 2001;285:2486-2497.
ATP III Framingham Risk Scoring


       Assessing CHD Risk in Women
                                        Step 4: Systolic Blood Pressure                              Step 6: Adding Up the Points
 Step 1: Age
                                         Systolic BP         Points       Points                      Age
   Years         Points                   (mm Hg)        if Untreated if Treated                      Total cholesterol
    20-34            -7                     <120               0              0                       HDL-cholesterol
    35-39            -3                    120-129             1              3                       Systolic blood pressure
    40-44             0                    130-139             2              4
                                                                                                      Smoking status
    45-49             3                    140-159             3              5
                                                                                                      Point total
    50-54             6                     160               4              6
    55-59             8
    60-64           10                                                                   Step 7: CHD Risk
    65-69           12                                                              Point Total 10-Year Risk         Point Total 10-Year
    70-74           14                                                              Risk
    75-79           16
 Step 2: Total Cholesterol                                                               <9         <1%                    20          11%
                                                                                          9          1%                    21          14%
        TC      Points at      Points at     Points at     Points
                                                                                         10          1%                    22          17%
 at Points at
     (mg/dL)    Age 20-39     Age 40-49 Age 50-59 Age 60-69 Age                          11          1%                    23          22%
 70-79                                                                                   12          1%                    24          27%
       <160         0              0             0               0           0           13          2%                    25        30%
      160-199       4              3             2               1           1           14          2%
      200-239       8              6             4               2           1           15          3%
      240-279      11              8             5               3           2           16          4%
       3: HDL-Cholesterol
 Step 280         13              10            7               4           2           17          5%
     HDL-C                                                                               18          6%
    (mg/dL)          Points      Step 5: Smoking Status
                                                                                         19          8%
      60              -1
                                                     Points at       Points at   Points at     Points
     50-59              0          at                Points at
     40-49              1                            Age 20-39       Age 40-49 Age 50-59 Age 60-69 Age
                                   70-79
      <40               2
                                   Nonsmoker         0                   0           0           0          0
 Note: Risk estimates were derivedfrom the experience9of
                                   Smoker               the Framingham Heart Study,
                                                                  7          4                   2          1
 a predominantly Caucasian population in Massachusetts, USA.
 Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults.              © 2001, Professional Postgraduate Services®
                                                                                                                      www.lipidhealth.org
 JAMA. 2001;285:2486-2497.
ATP III Framingham Risk Scoring


      Step 1: Age
                   Men                                           Women
        Years                  Points                   Years                  Points
        20-34                       -9                  20-34                         -7
        35-39                       -4                  35-39                         -3
        40-44                        0                  40-44                          0
        45-49                        3                  45-49                          3
        50-54                        6                  50-54                          6
        55-59                        8                  55-59                          8
        60-64                       10                  60-64                         10
        65-69                       11                  65-69                         12
        70-74                       12                  70-74                         14
        75-79                       13                  75-79                         16




 Expert Panel on Detection, Evaluation, and Treatment of High Blood
 Cholesterol in Adults. JAMA. 2001;285:2486-2497.
                                                                      © 2001, Professional Postgraduate Services®
                                                                                    www.lipidhealth.org
ATP III Framingham Risk Scoring


      Step 2: Total Cholesterol
   Men TC                     Points at          Points at            Points at      Points at Points
     at
        (mg/dL)              Age 20-39          Age 40-49          Age 50-59        Age 60-69             Age
     70-79
          <160                     0                   0                   0                0                   0
         160-199                   4                   3                   2                1                   0
         200-239                   7                   5                   3                1                   0
         240-279                   9                   6                   4                2                   1
          280                     11                  8                   5                3                   1
   Women
            TC               Points at          Points at          Points at        Points atPoints at
          (mg/dL)            Age 20-39          Age 40-49          Age 50-59        Age 60-69 Age 70-
     79
           <160                    0                  0                    0                0                       0
          160-199                  4                  3                    2                1                       1
          200-239                  8                  6                    4                2                       1
          240-279                 11                  8                    5                3                       2
           280                   13                  10                   7                4                       2
 Note: TC and HDL-C values should be the average of at least two fasting
 lipoprotein measurements.

 Expert Panel on Detection, Evaluation, and Treatment of High Blood               © 2001, Professional Postgraduate Services®
 Cholesterol in Adults. JAMA. 2001;285:2486-2497.                                               www.lipidhealth.org
ATP III Framingham Risk Scoring




      Step 3: HDL-Cholesterol
                         Men                                             Women
                HDL-C                                                  HDL-C
               (mg/dL)             Points                             (mg/dL)          Points
                 60                  -1                                60               -1
                 50-59                   0                             50-59                  0
                 40-49                   1                             40-49                  1
                  <40                    2                              <40                   2




 Note: HDL-C and TC values should be the average of at least two
 fasting lipoprotein measurements.

 Expert Panel on Detection, Evaluation, and Treatment of High Blood
 Cholesterol in Adults. JAMA. 2001;285:2486-2497.                               © 2001, Professional Postgraduate Services®
                                                                                              www.lipidhealth.org
ATP III Framingham Risk Scoring


             Step 4: Systolic Blood Pressure
                           Men
                              Systolic BP  Points                          Points
                               (mm Hg) if Untreated                     if Treated
                                 <120        0                               0
                                120-129      0                               1
                                130-139      1                               2
                                140-159      1                               2
                                 160        2                               3

                           Women
                              Systolic BP              Points       Points
                               (mm Hg)             if Untreated if Treated
                                 <120                    0              0
                                120-129                  1              3
                                130-139                  2              4
                                140-159                  3              5
                                 160                    4              6
 Note: The average of several BP measurements is needed for an accurate
 measurement of baseline BP. If an individual is on antihypertensive treatment,
 extra points are added.

 Expert Panel on Detection, Evaluation, and Treatment of High Blood                  © 2001, Professional Postgraduate Services®
                                                                                                   www.lipidhealth.org
 Cholesterol in Adults. JAMA. 2001;285:2486-2497.
ATP III Framingham Risk Scoring




   MenStep 5: Smoking Status
                           Points at              Points at      Points at   Points at Points
     at
                           Age 20-39 Age 40-49                  Age 50-59    Age 60-69                  Age
     70-79
     Nonsmoker                    0                   0               0               0                       0
     Smoker                       8                   5               3               1                       1
   Women
                           Points at              Points at      Points at   Points at Points
     at
                           Age 20-39 Age 40-49                  Age 50-59    Age 60-69                  Age
     70-79
     Nonsmoker                   0                    0               0               0                       0
     Smoker                      9                    7               4               2                       1


 Note: Any cigarette smoking in the past month.

 Expert Panel on Detection, Evaluation, and Treatment of High Blood
 Cholesterol in Adults. JAMA. 2001;285:2486-2497.                            © 2001, Professional Postgraduate Services®
                                                                                           www.lipidhealth.org
ATP III Framingham Risk Scoring

  Step 6: Adding Up the Points
  (Sum From Steps 1–5)
                       Age
                       Total cholesterol
                       HDL-cholesterol
                       Systolic blood pressure
                       Smoking status
                       Point total




 Expert Panel on Detection, Evaluation, and Treatment of High Blood
 Cholesterol in Adults. JAMA. 2001;285:2486-2497.
                                                                      © 2001, Professional Postgraduate Services®
                                                                                    www.lipidhealth.org
ATP III Framingham Risk Scoring


      Step 7: CHD Risk for Men
             Point Total            10-Year Risk                  Point Total      10-Year
             Risk
                  <0                       <1%                         11                  8%
                   0                        1%                        12                  10%
                   1                        1%                        13                  12%
                   2                        1%                        14                  16%
                   3                        1%                        15                  20%
                   4                        1%                        16                  25%
                   5                        2%                        17                30%
                   6                        2%
                   7                        3%
                   8                        4%
                   9                        5%
                  10                        6%
 Note: Determine the 10-year absolute risk for hard CHD (MI and
 coronary death) from point total.

 Expert Panel on Detection, Evaluation, and Treatment of High Blood
 Cholesterol in Adults. JAMA. 2001;285:2486-2497.                               © 2001, Professional Postgraduate Services®
                                                                                              www.lipidhealth.org
What is WJC’s 10-year absolute
risk
of fatal/nonfatal MI?
• A 12% absolute risk is derived from points
  assigned in Framingham Risk Scoring to:
   –   Age:       6
   –   TC:        3
   –   HDL-C:     2
   –   SBP:       2
   –   Total: 13 points

 In 1992 he exercised 14 minutes in a Bruce protocol exercise
stress test to 91% of his maximum predicted heart rate without
 any abnormal ECG changes. He started on a statin in 2001.
 But in Sept 2004, he needed urgent coronary bypass surgery.
ATP III Framingham Risk Scoring


      Step 7: CHD Risk for Women
             Point Total            10-Year Risk                  Point Total      10-Year
             Risk
                  <9                       <1%                        20                  11%
                   9                        1%                        21                  14%
                  10                        1%                        22                  17%
                  11                        1%                        23                  22%
                  12                        1%                        24                  27%
                  13                        2%                        25                30%
                  14                        2%
                  15                        3%
                  16                        4%
                  17                        5%
                  18                        6%
                  19                        8%
 Note: Determine the 10-year absolute risk for hard CHD (MI and
 coronary death) from point total.

 Expert Panel on Detection, Evaluation, and Treatment of High Blood
 Cholesterol in Adults. JAMA. 2001;285:2486-2497.                               © 2001, Professional Postgraduate Services®
                                                                                              www.lipidhealth.org
CHD Risk Equivalents
• Risk for major coronary events
  equal to that in established CHD
• 10-year risk for hard CHD >20%
Hard CHD = myocardial infarction + coronary
death
Diabetes as a CHD Risk
Equivalent
• 10-year risk for CHD  20%
• High mortality with established CHD
  – High mortality with acute MI
  – High mortality post acute MI
CHD Risk Equivalents
• Other clinical forms of
  atherosclerotic disease (peripheral
  arterial disease, abdominal aortic
  aneurysm, and symptomatic carotid
  artery disease)
• Diabetes
• Multiple risk factors that confer a 10-
  year risk for CHD >20%

				
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posted:4/10/2008
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