Cardiovascular Epidemiology:
Definitions Historical Perspectives and Assessing Risk of CVD Recent trends and population differences in CHD and CHD risk factors
Deaths in Thousands
500 410 400 300 200 100 0 A B C D E A B D F E 70 59 64 35 285 265 Males Females 461
47 38
A Total CVD B Cancer C Accidents
D Chronic Lower Respiratory Diseases E Diabetes Mellitus F Alzheimer’s Disease
Leading causes of death for all males and females (United States: 2004). Source: NCHS and NHLBI.
52%
13% .4% .5% 4% 6% 7%
Stroke
17%
Coronary Heart Disease Heart Failure Diseases of the Arteries Defects Rheumatic Fever/ Rheumatic Heart Disease
High Blood Pressure
Congenital Cardiovascular Other
Percentage breakdown of deaths from cardiovascular diseases (United States:2004)
Source: NCHS and NHLBI.
1 000
Deaths in Thousands
900 800 700 600 500 400 300 200 100 0
5 3 4 4 16 15 46 49 78 96 130 139 267 165 80 325
872
555
<25
25-34
35-44
45-54
55-64 CVD
65-74
75-84
85+
Total
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
Thrombus
Lipid core
Ross R. Nature. 1993;362:801-809.
Atherosclerotic Plaque Rupture and Thrombus Formation
Growth of thrombus
Intraluminal thrombus
Blood Flow
Intraplaque thrombus Adapted from Weissberg PL. Eur Heart J Supplements 1999:1:T13–18
Lipid pool
PDAY: Percentage of Right Coronary Artery Intimal Surface Affected With Early Atherosclerosis
30 20 10
Men
Raised lesions 30 Fatty streaks 20 10 0
Women
Intimal surface (%)
0
30 20
15-19 20-24 25-29 30-34 White
30
15-19 20-24 25-29 30-34 White
20 10
0
10
0
15-19 20-24 25-29 30-34 Black
15-1920-2425-2930-34 Black
Age (y)
PDAY= Pathobiological Determinants of Atherosclerosis in Youth. Strong JP, et al. JAMA. 1999;281:727-735.
Coronary Remodeling
Progression
Compensatory expansion maintains constant lumen
Expansion overcome: lumen narrows
Normal vessel
(Adapted from Glagov et al.) Glagov et al, N Engl J Med, 1987.
Minimal CAD
Moderate CAD
Severe CAD
Most Myocardial Infarctions Are Caused by Low-Grade Stenoses
Falk E et al, Circulation, 1995.
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.)
Vulnerable Versus Stable Atherosclerotic Plaques
Vulnerable Plaque
Lumen
Fibrous Cap Lipid Core
• Thin fibrous cap • Inflammatory cell infiltrates: proteolytic activity • Lipid-rich plaque
Stable Plaque
Lumen
Fibrous Cap
Lipid Core
• Thick fibrous cap • Smooth muscle cells: more extracellular matrix • 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)
100.0
Percent of Population
92.0 71.3 75.1 83.0
80.0 60.0 40.0 20.0 0.0 20-39 40-59 Males 14.8 9.4 39.1 39.5
60-79 Females
80+
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
Percent of Population
30.0 25.0 20.0 15.0 10.0 5.0 0.0 20-39 40-59 Men 60-79 Women 0.6 0.6 7.8 5.5 22.8 15.4
32.7 21.6
80+
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
New and Recurrent Attacks
500,000
410,000
400,000 300,000 200,000 100,000 0 29-44 45-64 Ages
88,000 34,000 10,000 250,000
372,000
Men Women
65+
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
Per 1,000 Persons
12 10 8 6 4 2 0 35-44 45-54 Ages 55-64 65-74 White Men Black Men White Women Black Women
Source: NHLBI’s ARIC surveillance study, 1987-2000.
16
Percent of Population
14.8 12.4
14 12 10 8 6 4 2 0 20-39 40-59 Men 60-79 Women 0.5 0.5 1.2 2.3 6.5 6.2
80+
Prevalence of stroke by age and sex (NHANES: 1999-2004).
Source: NCHS and NHLBI.
14
Percent of Population
12 10 8 6 4 2 0 20-39 40-59 Men 60-79 Women 0.3 0.2 2 1.5 7.2 5.2
11.6
12.4
80+
Prevalence of heart failure by age and sex (NHANES: 1999-2004). Source: NCHS and NHLBI.
Discharges in Thousands
700 600 500 400 300 200 100 0
79 80 85 90 95 00 04
Male
Female
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
Deaths in Thousands
500 480 460 440 420 400 380 0
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% At age 70 years: 34.9%
Lloyd-Jones et al. Lancet 1999; 353:89-92
31.7% 24.2%
_________________________________________________________________
____________________________________________________________
First Coronary Events: Framingham Study
________________________________________________________
Percent as Specified Event
Myocardial Infarction Age Men Women
35-64 43% 28% 65-84 55% 44%
Angina Pectoris Men Women
41% 28% 59% 41%
Sudden Death Men Women
9% 4% 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 35 30 25 20 15 10 5 0
Estimated 10-Year Rate (%)
37 25 20 13 5 5 8 27 Men Women
A
B
C
D
A
Blood Pressure (mm Hg) 120/80
B
140/90
C
140/90
D
140/90
Total Cholesterol (mg/dL)
HDL Cholesterol (mg/dL) Diabetes Cigarettes
mm Hg = millimeters of mercury mg/dL = milligrams per deciliter of blood
200
50 No No
240
50 No No
240
40 Yes No
240
40 Yes Yes
Source: Circulation 1998;97:1837-1847.
Estimated 10-Year Stroke Risk in 55Year-Old Adults According to Levels of Various Risk Factors
Framingham Heart Study
Estimated 10-Year Rate (%)
30 25 20 14.8 15 10 5 0 2.6 4 1.1 5.4 2 3.5 8.4 6.3 19.1 22.4 27
A
B
C
Men
D
Women
E
F
Systolic BP* Diabetes Cigarettes Prior Atrial Fib. Prior CVD
A 95-105 No No No No
B 130-148 No No No No
C 130-148 Yes No No No
D 130-148 Yes Yes No No
E 130-148 Yes Yes Yes No
F 130-148 Yes Yes Yes Yes
Source: Stroke 1991;22:312-318.
*BP in millimeters of mercury (mmHg)
30
Estimated 10-Year Rate (%)
27 22.4 Men W omen 14.8 19.1
25 20 15 10 5 0 2.6 4 1.1 2 5.4 3.5 8.4 6.3
A
Systolic BP* Diabetes Cigarettes Prior Atrial Fib. Prior CVD
B
A 95-105 No No No No
C
B 130-148 No No No No C 130-148 Yes No No No
D
D 130-148 Yes Yes No No
E
E 130-148 Yes Yes Yes No
F
F 130-148 Yes Yes Yes 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
Risk Ratio
2.5 2.5
2 2
2.2
Parental CVD <55 men, <65 Women NONE MATERNAL PATERNAL
1.5 1 1
1.0
1.7
1.7
1.7
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
Serum Cholesterol
Age: 35-64* Wome Men n
Age: 65-94
Men+
Women*
84-204
8
4
22
11
205-234 235-264 265-294
295-1124
*Trends Significant at P.001. +P.07.
13 14 15
26
5 4 7
10
24 26 23
38
15 17 17
32
Correlation Between Serum Cholesterol and CVD Mortality
30 6-Year CVD Death Rate Per 1000 25 20
Multiple Risk Factor Intervention Trial (MRFIT) N=325,346
Untreated Patients 55-57 years
50-54 years
15
45-49 years
10
5 0
40-44 years
35-39 years
Q1 (<182)
Q2 (182-202)
Q3 (203-220)
Q4 (221-244)
Q5 (>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 50 40
44
57
Cholesterol <200 mg 200-239 mg
>240 mg
Percent
30 20 10 0
34 29 19
33
Men
Women
Framingham Study: Subjects age 40 years
DM Lloyd-Jones et al Arch Intern Med 2003; 1966-1972
45 40 35 30 25 20 15 10 5 0
Percent of Population
39.0 32.0 32.0 32.0 34.0 32.0 30.0 31.0
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 25 20 15 10 5 0
25
26
28
16 13 9 9 7
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
208 206 204 202 200 198 196 194 192
206 204 202 199 197 204
205 202 201
NH White 1988-94
NH Black 1999-02
Mexican American 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
180 175 170 165 160 155 155 150 145 White Males Black Males 1976-80 1988-94 White Females 1999-02 2003-04 Black Females 163 163 156 171 165 166 161 170 166 163 164 172 174 168 161
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% 10% 8%
7.6
<120/80 mm Hg 120-129/80-84 mm Hg 130-139/85-89 mm Hg
Hazard Ratio*
SBP
10.1
Women Men 1.0 1.5 2.5 1.0 1.3 1.6
<120/80 120-129 130-139
6% 4% 2% 0% Women
2.8
1.9
5.8
4.4
H.R. adjusted for age, BMI, Cholesterol, Diabetes and smoking *P<.001
Men
Framingham Study: Subjects Ages 35-90 yrs.
Percent of Population
90.0 80.0 70.0 60.0 50.0 40.0 30.0 20.0 10.0 0.0 23.2 11.2 6.4 35-44
83.8 73.9 63.6 55.4 49.1 37.5 37.4 18.3 69.5
20-34
45-54 Men
55-64 Women
65-74
75+
Prevalence of high blood pressure in Adults by age and sex (NHANES: 1999-2004). Source: NCHS and NHLBI.
80 70 60 50 40 30 20 10 0
74.6 52.3
75.3 62.5 68.4
Percent of Population
35.8 24.6
39.8 34.3
Awareness
Treatment 20-39 40-59 60+
Controlled
Extent of awareness, treatment and control of high blood pressure by age (NHANES : 1999-2004.) Source: NCHS and NHLBI.
Percent of Population
50 40 30 20 10 0 NH WhiteOnly Men NH WhiteOnly Women NH Black or AA Men NH Black or AA Women 1999-04 Mexican Men Mexican Women 25.6 28.5 22.9 28.0 37.5 39.0 38.2 41.4 26.9 26.2 25.0 27.0
1988-94
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 80 70 60 50 40 30 20 10 0
Percent of Population
72.9
76.9 62.4 63.4 66.9 49.1 37.2 33.6 25.1
Awareness NH Whites
Treatment NH Blacks Mexican Americans
Controlled
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 Rate per 1000 Age Men Women 35-64 164 135 65-94 234 235
Risk Excess Risk Ratio per 1000 Men Women Men Women 4.7*** 7.4*** 129 117 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
250 200
206 210
Non-Smoker Reg. Cig. Smoker Filter Cig. Smoker
150 100 50 0 Total CHD Myocardial Infarction
119
112
210
59
40 35 30 25 20 15 10 5 0
37.3 33.4 24.1 23.9 18.9 17.8 20.4 20.2 15 11.3
Percent of Population
Men NH White NH Black Hispanic Asian
Women 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 40 35 30 25 20 15 10 5 0
Percent of Population
24.9
27
24.8 19.2 14 11.9
NH Whites
NH Blacks Males Females
Hispanics
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
_________________________________________________________________
Cardiovascular Event Coronary Disease Stroke Peripheral Artery Dis. Cardiac Failure All CVD Events
Age-adjusted Biennial Rate Age-adjusted Per 1000 Risk Ratio Men Women Men Women 39 21 1.5** 2.2*** 15 6 2.9*** 2.6*** 18 18 3.4*** 6.4*** 23 21 4.4*** 7.8*** 76 65 2.2*** 3.7***
_________________________________________________________________ Subjects 35-64 36-year Follow-up **P<.001,***P<.0001
14.0
13.2 10.7 11.0 10.9
Percent of Population
12.0 10.0 8.0 6.0 4.0 2.0 0.0 6.7
5.6
Men NH Whites NH Blacks
Women 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
Deaths/1000 Person Years
45.0 40.0 35.0 30.0 25.0 20.0 15.0 10.0 5.0 0.0 CHD Mortality CVD Mortality
2.6 4.3 4.8 6.3 17.0 10.9 7.8 5.3 16.7 11.5 8.6 28.1 30.0 26.1 21.1 17.1 14.4
44.1
No MetS or DM MetS w/o DM MetS w/DM DM only Prior CVD Prior CVD and DM
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)
Risk Factor Sum
2.4
1.8 1.2
(1971)
(1989)
Risk factors accumulate with weight gain
0.6
0
Q1 Thin
Q2
Q3
Q4
Q5 Obese
Overall
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
Percent of Population
34 30.2
30
20.6
26 16.8 17.1
20
10.7 12.2 12.8 15.7
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 16 14 12 10 8 6 4 2 0
18.7 16.3 11.6
Percent of Population
11 6.4 3.6
6.6 4.3
6-11
1971-74 1976-80 1988-94
12-19
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
Percent of Population
21.3 15.2 15.9 16.1 12.1
20 16 12
8.2
8 4 0 Males NH Whites NH Blacks Females 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 40 30 20 10 0
te hi M e al NH ck la B M e al Hi ic an sp M e al I e nd sla an di In e al rM iv at N e M e al te hi m Fe e al ck la B
45.7 34.2 26.4 18.4 27.0 37.5 32.5 25.0 20.4 34.4 28.3 23.8 21.6 33.9
44.8 39.6 31.5 24.0 36.3 31.8
m Fe
e al ic an sp
e al m Fe ic I
NH
W
/ an i As
ic cif Pa Am
ka as l /A
NH
W
NH
Hi
e nd sla
m Fe r
e al a iv at N e
...
.
As
if ac P n/ ia
Am
.
sk la A n/ ia nd I
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.
50 45 40 35 30 25 20 15 10 5 0
46.9 NH White 38.2 39 30.2 21.3 26.5 NH Black Hispanic
Percent of Population
Male Sex and Race/Ethnicity
Female
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 CommunityWide 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 cholesterollowering 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
– Age (men 45 years; women 55 years)
CHD in male first degree relative <55 years CHD in female first degree relative <65 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
High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.
© 2001, Professional Postgraduate Services® www.lipidhealth.org
ATP III Framingham Risk Scoring
Assessing CHD Risk in Men
Step 1: Age
Years 20-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79
Points -9 -4 0 3 6 8 10 11 12 13
Step 4: Systolic Blood Pressure
Systolic BP (mm Hg) <120 120-129 130-139 140-159 160 Points Points if Untreated if Treated 0 0 0 1 1 2 1 2 2 3
Step 6: Adding Up the Points
Age Total cholesterol HDL-cholesterol Systolic blood pressure Smoking status Point total
Step 7: CHD Risk
Point Total 10-Year Risk Risk <0 <1% 0 1% 1 1% 2 1% 3 1% 4 1% 5 2% 6 2% 7 3% 8 4% 9 5% 10 6% Points at Points Point Total10-Year 11 12 13 14 15 16 17 8% 10% 12% 16% 20% 25% 30%
Step 2: Total Cholesterol TC Points at at Points at (mg/dL) Age 20-39 70-79 <160 0 160-199 4 200-239 7 240-279 9 280 11 Step 3: HDL-Cholesterol HDL-C (mg/dL) 60 Points -1 Points at Points at Points
Age 40-49 Age 50-59 Age 60-69Age
0 3 5 6 8
0 2 3 4 5
0 1 1 2 3
0 0 0 1 1
Step 5: Smoking Status
50-59
40-49
0
1
Age 40-49 Age 50-59 Age 60-69Age 70-79 <40 2 Nonsmoker 0 0 0 0 0 Note: Risk estimates were derived from the experience 8 the Framingham Heart Study, of Smoker 5 3 1 1
at
Points at Points at Age 20-39
Points at
a predominantly Caucasian population in Massachusetts, USA. 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
Assessing CHD Risk in Women
Step 1: Age Years Points 20-34 -7 35-39 -3 40-44 0 45-49 3 50-54 6 55-59 8 60-64 10 65-69 12 70-74 14 75-79 16 Step 2: Total Cholesterol TC Points at at Points at (mg/dL) Age 20-39 70-79 <160 0 160-199 4 200-239 8 240-279 11 13 Step 280 3: HDL-Cholesterol HDL-C (mg/dL) 60 Points -1
Step 4: Systolic Blood Pressure
Systolic BP (mm Hg) <120 120-129 130-139 140-159 160 Points Points if Untreated if Treated 0 0 1 3 2 4 3 5 4 6
Step 6: Adding Up the Points
Age Total cholesterol HDL-cholesterol Systolic blood pressure Smoking status Point total
Step 7: CHD Risk
Point Total 10-Year Risk Risk <9 <1% 9 1% 10 1% 11 1% 12 1% 13 2% 14 2% 15 3% 16 4% 17 5% 18 6% 19 8% Points at Points Point Total10-Year 20 21 22 23 24 25 11% 14% 17% 22% 27% 30%
Points at
Points at
Points
Age 40-49 Age 50-59 Age 60-69Age
0 3 6 8 10
0 2 4 5 7
0 1 2 3 4
0 1 1 2 2
Step 5: Smoking Status
50-59
40-49
0
1
Age 40-49 Age 50-59 Age 60-69Age 70-79 <40 2 Nonsmoker 0 0 0 0 0 Note: Risk estimates were derived from the experience 9 the Framingham Heart Study, of Smoker 7 4 2 1
at
Points at Points at Age 20-39
Points at
a predominantly Caucasian population in Massachusetts, USA. 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 1: Age
Men
Years
20-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79
Women
Points
-9 -4 0 3 6 8 10 11 12 13
Years
20-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79
Points
-7 -3 0 3 6 8 10 12 14 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
at
TC Points at Age 20-39 0 4 7 9 11 Points at Age 40-49 0 3 5 6 8 Points at Age 50-59 0 2 3 4 5 Points at Points Age 60-69 0 1 1 2 3 Age 0 0 0 1 1 (mg/dL) 70-79 <160 160-199 200-239 240-279 280
Women
79 TC (mg/dL)
<160 160-199 200-239 240-279 280
Points at Age 20-39
0 4 8 11 13
Points at Age 40-49
0 3 6 8 10
Points at Age 50-59
0 2 4 5 7
Points atPoints at Age 60-69 Age 700 1 2 3 4 0 1 1 2 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 Cholesterol in Adults. JAMA. 2001;285:2486-2497.
© 2001, Professional Postgraduate Services® www.lipidhealth.org
ATP III Framingham Risk Scoring
Step 3: HDL-Cholesterol
Men
HDL-C (mg/dL) 60 50-59
Women
Points -1
0 HDL-C (mg/dL) 60 50-59
Points -1
0
40-49 <40
1 2
40-49 <40
1 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 (mm Hg) if Untreated <120 0 120-129 0 130-139 1 140-159 1 160 2 Points if Treated 0 1 2 2 3
Women
Systolic BP (mm Hg) <120 120-129 130-139 140-159 160 Points Points if Untreated if Treated 0 0 1 3 2 4 3 5 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 Cholesterol in Adults. JAMA. 2001;285:2486-2497.
© 2001, Professional Postgraduate Services® www.lipidhealth.org
ATP III Framingham Risk Scoring
Men
at
Step 5: Smoking Status
Points at Points at Points at Age 20-39 0 8 Points at Age 20-39 0 9 Age 40-49 0 5 Points at Age 40-49 0 7 Age 50-59 0 3 Points at Age 50-59 0 4
Points at Points Age 60-69 0 1 Age 0 1
70-79 Nonsmoker Smoker
Women
at 70-79 Nonsmoker Smoker
Points at Points Age 60-69 0 2 Age 0 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 Risk <0 0 1 2 3 4 5 6 7 8 9 10 10-Year Risk <1% 1% 1% 1% 1% 1% 2% 2% 3% 4% 5% 6% Point Total 11 12 13 14 15 16 17 10-Year 8% 10% 12% 16% 20% 25% 30%
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 Risk <9 9 10 11 12 13 14 15 16 17 18 19 10-Year Risk <1% 1% 1% 1% 1% 2% 2% 3% 4% 5% 6% 8% Point Total 20 21 22 23 24 25 10-Year 11% 14% 17% 22% 27% 30%
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 10year risk for CHD >20%