By Hatim Jaber MD MPH JBCM PhD 21- 2-2017

1. Faculty of MedicineCardiovascular SystemEpidemiology and risk factors of Cardiovascular diseases (CVDs)Prevention and control of Cardiovascular diseases By HatimJaber MD MPH JBCM PhD 21- 2-2017

2. Presentation outline

3. What are cardiovascular diseases? Cardiovascular diseases (CVDs) are a group of disorders of the heart and blood vessels and they include: • coronary heart disease – disease of the blood vessels supplying the heart muscle; • cerebrovasculardisease – disease of the blood vessels supplying the brain; • peripheral arterial disease – disease of blood vessels supplying the arms and legs; • rheumatic heart disease – damage to the heart muscle and heart valves from rheumatic fever, caused by streptococcal bacteria; • congenital heartdisease – malformations of heart structure existing at birth; • deep vein thrombosis and pulmonary embolism – blood clots in the leg veins, which can dislodge and move to the heart and lungs.

4. Definitions • 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, and revascularization (perceutaneous coronary interventions, or PCI such as angioplasty and stents)

5. The different types of CVDs 1. CVDs due to atherosclerosis: • 􀁑 ischaemic heart disease or coronary artery disease (e.g. heart attack) • 􀁑 cerebrovascular disease (e.g. stroke) • 􀁑 diseases of the aorta and arteries, including hypertension and peripheral vascular disease. 2. Other CVDs • 􀁑 congenital heart disease • 􀁑 rheumatic heart disease • 􀁑 cardiomyopathies • 􀁑 cardiac arrhythmias.

6. Types of Cardiovascular Disease • - Coronary heart disease (CHD, ischemic heart disease, heart attack, myocardial infarction, angina pectoris) • - Cerebrovascular disease (stroke, TIA, transient ischemic attack) • - Hypertensive heart disease • - Peripheral vascular disease • - Heart failure ?????????????????????? • - Rheumatic heart disease (streptococcal infection) • - Congenital heart disease • - Cardiomyopathies

7. Definitions (cont.) • SURROGATE MEASURES include: carotid intimal medial thickness (IMT), coronary calcium, angiographic stenosis, brachial ultrasound flow mediated dilatation (FMD) • Hard endpoints include: --- myocardial infarction, --- CHD death, - and stroke

8. Public Health Significance • - Leading cause of mortality in developed countries and a rising tendency in developing countries (disease of civilization) • - A major impact on life expectancy • - Significantly contributes to morbidity and death rates in the middle aged population: -potential life years lost, - common cause of premature death, - labor force (economic costs), - family life • - Morbidity: nearly 30% of all disability cases • - Contributes to deterioration of the quality of life

9. Tasks of Cardiovascular Epidemiology • - Detection of the occurrence and distribution of CVD in populations, surveillance, monitoring, trends of changes • - Study of the natural history of CVD • - Formulation and testing of etiological hypotheses (risk factors) • - Contribution to the development of cardiovascular prevention programs and the measurement of their effectiveness

10. Descriptive Epidemiology I. Distribution Patterns in the World---KEY FACTS • CVDs are the number 1 cause of death globally: more people die annually from CVDs than from any other cause. • An estimated 17.5 million people died from CVDs in 2012, representing 31% of all global deaths. Of these deaths, an estimated 7.4 million were due to coronary heart disease and 6.7 million were due to stroke . • Over three quarters of CVD deaths take place in low- and middle-income countries. • Out of the 16 million deaths under the age of 70 due to noncommunicable diseases, 82% are in low and middle income countries and 37% are caused by CVDs.

11. CVDs are responsible for over 17.3 million deaths per year and are the leading causes of death in the world

12. KEY FACTS • Most cardiovascular diseases can be prevented by addressing behavioral risk factors such as: • tobacco use, • unhealthy diet and obesity, • physical inactivity • and harmful use of alcohol using population-wide strategies. • People with cardiovascular disease or who are at high cardiovascular risk (due to the presence of one or more risk factors such as hypertension, diabetes, hyperlipidaemia or already established disease) need early detection and management using counseling and medicines, as appropriate

13. Descriptive Epidemiology II. AGE • Question: What is the relative amount of CVD in death rates in different age groups? • - Early lesions of blood vessel, atherosclerotic plaques: around 20 years - adult lifestyle patterns usually start in childhood and youth (smoking, dietary habits, sporting behavior, etc.) • - Increase in CVD morbidity and mortality: in age-group of 30-44 years • - Premature death (<64 years of age, or 25-64 years): in the elderly population more difficult to interpret death rate due to multiple ill health causes

14. PROPORTION OF MORTALITY IN DIFFERENT AGE-GROUPS (MEN) 4,7% 100% 14,0% 14,9% 90% 80% 26,0% 61,5% 24,6% 70% external 60% others cancer 50% 26,9% CVD 40% 55,8% 22,5% 30% 32,7% 20% 11,4% 10% 4,6% 0% 1-24 yrs 25-64 yrs >65 yrs

15. PROPORTION OF MORTALITY IN DIFFERENT AGE-GROUPS (WOMEN) 4,8% 100% 8,2% 90% 18,3% 40,0% 24,0% 80% 12,2% 70% external 60% others 36,5% 50% cancer 35,0% CVD 40% 64,7% 30% 20% 17,7% 31,3% 10% 7,3% 0% 1-24 yrs 25-64 yrs >65 yrs

16. Descriptive Epidemiology III. SEX • Question: What is the relative amount of CVD in death rates in women and men? • - Widespread idea: CVD is often thought to be a disease of middle-aged men. • - Cardiovascular mortality (fatal cases) are more common among men. However, CVD affect nearly as many women as men, albeit at an older age • - Women: special case (WHO, 2004) • a., Higher risk in women than men (smoking, high triglyceride levels) • b., Higher prevalence of certain risk factors in women (diabetes mellitus, depression) • c., Gender-specific risk factors (risks for women only) (oral contraceptives, hormone replacement therapy, polycystic ovary syndrome)

17. Deaths due to heart attacks, strokes and other types of CVDs as a proportion of total cardiovascular deaths for males and females

18. Descriptive Epidemiology IV. ETHNICITY • Question: What is the relative amount of CVD in death rates in different ethnic groups? • - In the US: increased cardiovascular disease deaths in African-American and South-Asian populations in comparison with Whites • - Increased stroke risk in African-American, some Hispanic American, Chinese, and Japanese populations • - Migration: Ni-Hon-San Study: Japanese living in Japan had the lowest rates of CHD and cholesterol levels, those living in Hawaii had intermediate rates for both, those living in San Francisco had the highest rates for both

19. Descriptive Epidemiology V. TIME and PLACE • Question: What is the relative amount of CVD in different geographical places? What are the time trends? International and regional characteristics of distribution • SDR: Standardized Death Rate • Direct mode of standardization, using the age distribution of a hypothetical European standard population • Premature death rates for comparison purposes (<64 years of age)

21. Descriptive EpidemiologyVI. World Trends • Developed countries: decreasing tendencies (e.g, USA: 30% between 1988-98, Sweden: 42%) • - improvement of lifestyle factors, for example, a decrease of smoking and a higher level of health consciousness in many developed countries • - better diagnostic and therapeutic procedures (e.g., bypass surgeries, hypertension screening, pharmacological treatment of hypertension and hypercholesterinaemia, access to health care) • Developing countries: increasing tendencies • - increasing longevity, urbanization, and western type lifestyle

22. Descriptive EpidemiologyVII. International Comparisons • Aims: • a., Where are the rates higher or lower? • b., Interpretation of time trends • c., Inequalities in cardiovascular death

24. NCD deaths by cause in some Arab countries

25. Concept of cardiovascular “risk factors”

26. What are the risk factors for cardiovascular disease • The most important behavioral risk factors of heart disease and stroke are: • unhealthy diet, • -physical inactivity, • tobacco use and • harmful use of alcohol. The effects of behavioral risk factors may show up in individuals as raised blood pressure, raised blood glucose, raised blood lipids, and overweight and obesity. • These “intermediate risks factors” can be measured in primary care facilities and indicate an increased risk of developing a heart attack, stroke, heart failure and other complications.

27. Major Risk Factors • Cigarette smoking (passive smoking?) • Elevated total or LDL-cholesterol • 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) † HDL cholesterol 60 mg/dL counts as a “negative” risk factor; its presence removes one risk factor from the total count.

28. Other Recognized Risk Factors • Obesity: Body Mass Index (BMI) • Weight (kg)/height (m2) • Weight (lb)/height (in2) x 703 • Obesity BMI >30 kg/m2 with overweight defined as 25-<30 kg/m 2 • Abdominal obesity involves waist circumference >40 in. in men, >35 in. in women • Physical inactivity: most experts recommend at least 30 minutes moderate activity at least 4-5 days/week

29. "the causes of the causes” • There are also a number of underlying determinants of CVDs or "the causes of the causes". • These are a reflection of the major forces driving social, economic and cultural change – globalization, urbanization and population ageing. • Other determinants of CVDs include poverty, stress and hereditary factors.

30. Life-Habit Risk Factors • Obesity (BMI  30) • Physical inactivity • Atherogenic diet

31. Prevalence of High Blood Pressure in Americans by Age and Sex NHANES: 1999-2002 Source: CDC/NCHS and NHLBI.

32. 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

33. Risk Factor Concepts in Primary Prevention • Nonmodifiable risk factors include: age, sex, 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.

34. 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.

35. 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

36. Materials Developed for 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

37. 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

38. How can the burden of cardiovascular diseases be reduced • “Best buys” or very cost effective interventions that are feasible to be implemented even in low-resource settings have been identified by WHO for prevention and control of cardiovascular diseases. • They include two types of interventions: population-wide and individual, which are recommended to be used in combination to reduce the greatest cardiovascular disease burden. • Examples of population-wide interventions that can be implemented to reduce CVDs include: • - comprehensive tobacco control policies • - taxation to reduce the intake of foods that are high in fat, sugar and salt • - building walking and cycle paths to increase physical activity • - strategies to reduce harmful use of alcohol • - providing healthy school meals to children. • .

42. Framingham Milestones • 1960: cigarette smoking found to increase the risk of heart disease • 1961: Cholesterol level, blood pressure, and EKG abnormalities found to increase the risk of heart disease • 1967: physical activity found to reduce the risk of heart disease; obesity found to increase the risk of heart disease • 1970: High blood pressure found to increase the risk of stroke

43. Framingham Milestones • 1976: Menopause found to increase the risk of heart disease • 1978: Psychosocial issues found to affect the risk of heart disease • 1988: High levels of HDL found to reduce risk of death • 1994: Enlarged left ventricle found to increase the risk of stroke • 1996: Progression from hypertension to heart failure described

44. CVD in Men and Women • CVD mortality in men is holding steady; in women it is increasing • Women have comparable CVD rates about 10-15 years later than men, but the gap diminishes with age • 82% of coronary events in women are attributable to unhealthy diet, lack of activity, cigarette use, and overweight

45. The Decrease in CVD Mortality • 25% is due to primary prevention • 75% is due to behavioral changes affecting risk factors or improvements in treatment

46. Benefits of Risk Factor Reduction • 50-70% lower risk in former vs current smokers within 5 years of cessation • 2-3% decline in risk for each reduction of 1% serum cholesterol • 2-3% decline in risk for each reduction of 1 mm Hg in diastolic blood pressure • 35-55% lower risk for those who maintain desirable body weight as compared to those 20%+ above

47. Benefits of Risk Factor Reduction • 45% lower risk for those who maintain an active lifestyle compared with a sedentary lifestyle • 35% lower risk in aspirin users compared with nonusers

48. Major Risk Factors That Modify LDL Goals • 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 • CHD in female first degree relative <65 • Age (men 45 years; women 55 years)

49. Emerging Risk Factors • Lipoprotein (a) • Homocysteine • Prothrombotic factors • Proinflammatory factors • Impaired fasting glucose • Subclinical atherosclerosis

50. 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% • *HDL cholesterol 60 mg/dL counts as a “negative” risk factor; its presence removes one risk factor from the total count.