Epidemiology a nd Prevention of Cardiovascular Diseases

1. EpidemiologyandPrevention of CardiovascularDiseases Prof.Dr Selma KARABEY

2. History • Claudius Galen (A.D.130-200): Elaborated the concept that ‘’the heart is a source of heat and the blood vessels carry pneuma, life-sustaining spirit of the vital organs.’’

3. History Andreas Vesalius (1543): Galen’s erroneus teachings were entrenched for 1300 years, until Andreas Vesalius corrected his anatomy.

4. History William Harvey (1616): Proposed that the blood circulation is the force of the heart.

5. Theterm of cardiovasculardiseases • Coronary heart disease (CHD-Myocardial infarction,angina,coronary insufficiency,coronary death) • Cerebrovascular disease (Stroke and transient ischemic attacks) • Peripheral vascular disease • Congestive heart failure • Hypertension • Valvular and congenital heart disease

6. Definition andclassification Cardiovasculardisease: Theleadingcause of CVD isaterosklerosis, a pathologyaffectingthewalls of largeandmediumarteries. • Injuryanddeposits of cholestrol in thewall • Inflamationandcellularinfiltration • Calsification • Obstruction of bloodflow • Inadequateperfusion

7. Definition andclassification-3 CoronaryHeartDisease: • CHD remainstheleadingcause of adultdeath in industrialsocieties, althoughitsincidencedifferswidely. • Whiledeathsfrom CHD aredecreasing in industrializednations, theyareincreasingdramatically in othersparticularly in thedevelopingworld. • Dynamicnationaltrends in CVD deaths, bothupwardanddownward. • Rapidchanges in CVD risk amongmigrantpopulations.

8. Definition andclassification-2 Stroke: Ischaemicstroke: 1)Atheroscleroticstenosisorocclusion 2)Cardio-embolism 3)Small vesseldisease 4)Non-atheroscleroticvasculopathies , centralnervoussysteminfections (cryptococcus),sicklecelldisease, polycythemia Haemorrhagicstroke: 1) Subarachnoidhaemorrhages 2) Intraparenchymalhaemorrhages

9. Global CVD epidemic • Noncommunicable diseases were responsible for two-thirds of all deathsglobally in 2011, up from 60% in 2000. (Cardiovascular diseases, cancers, diabetes and chronic lung diseases) • Proportion of deaths that are due to NCDs, high-incomecountries have the highest proportion – 87% of all deaths were caused by NCDs – followed by upper-middleincomecountries (81%). The proportions are lower in low-incomecountries (36%) and lower-middle income countries (56%).

10. Global CVD epidemic-2 • Cardiovasculardiseaseskillednearly17 millionpeople in 2011, thatis 3 in 10 deaths, of these 7 millionpeopledied of ischaemicheartdiseaseand6.2 milliondied of stroke. • The number of people who die from CVDs, mainly from heart disease and stroke, will increase to reach 23.3million by 2030. (WHO 2013)

11. 3 WHO, The top 10 causes of death, 2011

12. WHO, The top 10 causes of death , 2011

13. 3 Global Atlas on cardiovascular disease prevention and control , WHO, 2011

14. WHO, The top 10 causes of death ,2011

15. WHO, The top 10 causes of death2011, Deaths per 1000 population

17. KeyMessages • Risk factors of CVDs are similar both for men and women. • Every year 8.6 million women die from CVDs. • CVD affects as many women as men.

18. Global Atlas on cardiovasculardisease preventionandcontrol , WHO, 2011

19. Global Atlas on cardiovascular disease prevention and control , WHO, 2011

20. Global Atlas on cardiovascular disease prevention and control , WHO, 2011

21. Epidemiology of CVD in Turkey • Cardiovascular diseases are the first death causes, at the national level with 203.457 deathin Turkey (47.73% of all causes of death ) • 102.386 mendied by the cause of cardiovascular diseases (43.89% of all causes of death ) • 103.071 womendied by the cause of cardiovascular diseases (52.27% of all causes of death )

22. Epidemiology of CVD in Turkey-2 • In Turkey cardiovascular diseases are the primary cause of total burden of disease (DALYs10,802,494) at the national level , with a ratio of 19.32% (2,086,527 DALYs) • 20.5% of the total burden of disease in men is caused by cardiovascular diseases. • 18 % of the total burden of disease in women is caused by cardiovascular diseases. • (Turkey Cardiovasculer Diseases Prevention and Control Programme 2010-2014)

23. Incidenceandprevalenceof CVD in Turkey Incidence Rate (100.000) Prevalence(1000) CardiovascularDisease CardiovascularDisease Wo men Men Women Total Men Total Rheumatic heart disease Heart disease caused by HT Angina Pectoris Acute MI CongestiveHeartDisease CerebrovascularDisease Long Term Stroke Inflammatory Heart Disease Others UYH-ME Study, 2004

24. Respiratory System Diseases Maternal and prenatal causes Infection Diseases(Ex.HIV/Aids) Injuries Digestive System Diseases Cancers Diabetes Mellitus %2 Others %5 Cardiovascular d. %43 MEN 233283 Deaths, Turkey, 2004 Türkiye Kalp ve Damar Hastalıklarını Kontrol ve Önleme Programı, 2004

25. Diabetes Mellitus Digestive System Diseases Others Injuries Maternal and prenatal causes Respiratory System Diseases Cardiovascular d. %43 Infection Diseases(Ex.HIV/Aids) Cancers %11 Türkiye Kalp ve Damar Hastalıklarını Kontrol ve Önleme Programı, 2004 Women 197177 Deaths,Turkey, 2004

26. Risk Factors of CVD

27. Global Atlas on cardiovascular disease prevention and control , WHO, 2011

28. Risk Factors of CVD-2 • Age is a powerful cardiovascular risk factor.The rapidly growing burden of CVD in LMICS increases by population ageing. • According to United Nations(UN) projections, in 2025 there will be 1.2 billion elderly people worldwide with %71 of them likely to be in developing countries.

29. KeyMessages • Ageing, globalization and urbanization drive the cardiovascular epidemic that is shaped by the rise of behavioural risk factors. • Unregulated globalization and unplanned urbanization increase the risk of exposure to cardiovascular risk factors and are detrimental to cardiovascular health.

30. Diet • Fat: Thosebloodcholesterollevelswere a strongpredictor of coronaryheartdisease in initiallyhealthypopulationsfollowedmorethan 25 years.(Blackburn Q Jacobs 1984) • Animalfats, specificallysaturatedfatandcholesterol. • Carbohydrates: Higherintake of complexcarbohydrates, is foundwithlow CHD mortality. • But a positiveassociation is foundbetweenrefinedsugarsand CHD. • Fruitsandvegetables, alsocontainfiberthatdecreasestheabsorption of fatandcholesterol in theintestines.

31. Alcohol Alcohol consumption is associated with • increased blood pressure and the risk of stroke • increased high-density lipoprotein cholesterol and triglycerides. • the effect on fibrinojen, platelet aggregation and fibrinolysis. • congestive cardiomyopathy, cardiac arrhythmias, sudden death.

32. Alcohol-2 • Moderateintake of alcohol is associatedwithlower risk of coronaryheartdiseasewhencomparedwithnon-drinkers. • Somehavesuggestedwine is theessentialform,whileothersfindthatotheralcoholicbeveragessuch as beerandspiritsareequallyimplicated.

33. Vitamins, mineralsandfoodsupplements Preventive Causing Homocysteine: A product of methioninemetabolismandelevatedbloodlevels of homocystein is associatedwith CHD (Osgamian et al.1999) • Vitamin C • VitaminE • B-carotene • Copper • Iron • Selenium • Fish oil • Fibre

35. Blood lipids • LDL (Lowdensitylipoprotein) is mostatherogenic form • Higherlevels of HDL(High densitylipoprotein) areassociatedwithlessdisease • Thelevels of serum triglyceridesmeasured in thefastingstateareassociatedwithcoronaryheartdisease • Blood cholesterol can be loweredamongadultswithmoderatechanges in dietandloss of weight

38. Cigarettesmoking • Cigarettesmokingaddicts20-80 percent of adult men worldwidewithsomewhatlowerproportion of adultwomenaddicted. • Cigarettesmokingbegins in youthandandgraduallyincreasesuntil it becomesnicotineaddiction. • Inrecentyears, thefocus has shiftedtoenvironmentaltobaccosmokewhichaffectsnon-smokers in publicandprivatesettings.

39. Cigarette smoking-2 • A chronicpromoter of atheroscleroticlesions, thismay be theresult of injurytothearterialendothelium • Acute risk factorforincreasingsympatheticstimulation • Enhancingclotting • Pharmacologicaleffects of nicotineandcarbonmonoxideareplateletadhesion, acutecoronaryconstrictionandtachycardia • Linkedtomyocardialinfarction, suddendeath, strokeandperipheralvasculardiseases

41. OverweightandObesity • Obesity is associatedwithelevatedbloodpressure, hyperlipidaemia, diabetesmellitusandinsulinresistance. • Expertpanelssuggest a body massindex (BMI) above 25 is classified as overweightandabove 30 as obese. (Eckel-Krauss 1998) • Oneunit in BMI wasassociatedwith12 percentincreasein the risk of hypertension. (NursesHealthStudy 1998) • Bothinsulinresistanceandhyperglycaemiaaresignificantlyreducedwhenpatientsloseweight. (Paiseyet al. 1998)

42. Diabetes, HyperglycaemiaandHyperinsulinaemia • Large vessel disease associated with DM in myocardial infarction,stroke,and periferial vascular disease. • Microvascular disease is associated with retinopathy, renal disease and cardiomyopathy. • Diabetes and hyperglycaemia are strongly related to atherosclerosis,obesity and abnormal lipit pattern.

43. Diabetes, HyperglycaemiaandHyperinsulinaemia-2 • Thetreatment of diabetes is based on control of bloodglucoseandtreatmentof associated risk factors. • Lifestylestrategies, weightlossandphysicalactivitycan be effectiveat reducingbloodglucoseandcontrollingtheassociated risk factors(Type 2 diabetes) • ForType 1 diabetes, insulinforglucosecontrolandcontrol of associated risk factors can reducesomediabeticcomplications.

44. Criteria for the Diagnosis of Diabetes ADA.Classification and Diabetes Care.2013

45. PhysicalInactivity • Physical inactivity is associated with acute myocardial infarction and sudden death both for the initial event and recurrent events. • Physical inactivity is associated with known risk factors including hypertension, hyperlipidaemia, diabetes mellitus and obesity.

46. Physical Inactivity-2 • Powel et al. calculateda relative risk of 1.9comparedwithsedentaryindividuals in 1987. • TheMultiple Risk FactorInterventionTrial of over12.000 men demonstratedsimilarrelationshipthosewithregularleisure time physicalactivityhavinglower risk of coronaryhearthdiseaseanddeath. (Leon et al.1987)

47. Psychosocialfactors • Psychosocial factors including personality characteristics and the social environment are populary believed to play an important role in cardiovascular disease. • Type A behavior is characterized by aggressiveness, competitive drive, preoccupation with deadlines, and time urgency.

48. Psychosocialfactors-2 • In the Western Collaborative Group Study, a prospective cohort of 3000 men was assessed by the structured interview.The relative risk of fatal and non-fatal coronary heart disease was approximately 2 for type A men. • Recent research suggests that anger or hostility is an acute than chronic risk factor and associated with plaque rupture. (Muller et al. 1997)

50. KeyMessages • Improving the nutrition of the girls and women can prevent CVD in future generations. • Implementation of policies to promote healthy lifestyles in children and youth is essential for prevention of CVD. • Undernutrition of fetal life and infancy increases an individual’s vulnerability to CVD. • Healthy behaviours are learned in childhood and continue in adulthood.