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Cardiovascular Epidemiology, Prevention & Control

Cardiovascular Epidemiology, Prevention & Control. Ahmed Mandil, Hafsa Raheel Family & Community Medicine Dept King Saud University. Session objectives. By the end of the session students should be able to understand the: Public health significance of CVD Descriptive CVD Epidemiology

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Cardiovascular Epidemiology, Prevention & Control

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  1. Cardiovascular Epidemiology, Prevention & Control Ahmed Mandil, Hafsa Raheel Family & Community Medicine Dept King Saud University

  2. Session objectives By the end of the session students should be able to understand the: • Public health significance of CVD • Descriptive CVD Epidemiology • Analytical CVD Epidemiology • CVD Prevention and control (interventional epidemiology) CVD Epidemiology

  3. Introduction • Cardiovascular diseases are leading causes of morbidity and mortality burdens worldwide, more in developed nations, but developing nations are catching up very quickly • Someone has a heart attack every two minutes (British Heart Foundation) CVD Epidemiology

  4. CVD’s DEFINITION • The World Health Organization (2015) defines CVDs as diseases of the heart and vascular system that can affect other organs including: coronary heart disease (CHD), cerebrovascular stroke, arterial peripheral disease and HTN, as well as other CVDs such as congenital heart disease, rheumatic heart disease, cardiac arrhythmias and cardiomyopathies (WHO, 2015b). • Public Health England (2013) defines CVD as disorders of the heart and blood vessels including CHD (angina, heart attack or heart failure) and cerebrovascular disease (stroke) (Public Health, 2013). • The Saudi Ministry of Health has adopted the WHO CVD's definition (Saudi-MOH, 2012, WHO, 2015b); • For the purposes of consistency of approach and comparison of findings, the WHO (2015) definition will be utilised. CVD Epidemiology

  5. EPI OF CVD’s • The cardiovascular disease epidemic is growing steadily worldwide, representing one of the 21st century's greatest challenges (Yusuf et al., 2001b, Yusuf et al., 2001a, WHO-NCD-status, 2014 , WHO, 2015b). • WHO ascertains that CVDs are the most common cause of death, not only in developed nations but also in the majority of developing countries, where they are still struggling with other health priorities such as CDs, violence, injuries, and maternal and perinatal mortality (WHO-Action-Plan, 2013 , Mendis and Chestnov, 2014, WHO, 2015b). • WHO indicates that, in 2012 CVDs killed 18 million people worldwide, representing one third of the global deaths; of these, 7.4 million were attributed to CHD and 6.7 million to stroke. More than 75% of cardiovascular deaths and majority of premature deaths (82%) occur in Low-Middle Income Countries (LMICs) (Murray et al., 2012, WHO-NCD-status, 2014 , WHO, 2015b). • Substantial evidence shows that, in the last four decades, developed countries have achieved a marked decline in CVD mortality, owing to reduction in CVRF levels, evidence-based cost-effective CVD management, and prevention and surveillance programs (Unal et al., 2004, Laatikainen et al., 2005, Ford and Capewell, 2007, O'Flaherty et al., 2013, Unal et al., 2013). • In contrast, trends of CVD attributed deaths are increasing in most LMICs, where most of these deaths occurred at a younger age, given that LMICs are still grappling with the rising tide of CVD (Beaglehole et al., 2008, Unal et al., 2013). • Moreover, the WHO statistical report (2014) shows that heart disease and stroke are among the top three (the third is lower respiratory infection) causes of years of healthy-life lost (YHLL) due to the premature death worldwide (WHO-World-Health-Statistic, 2014). CVD Epidemiology

  6. The Epidemiological Transition • Omran (1971) defines the ‘Epidemiological Transition’ as shifts in recorded cause of deaths from CD to NCD. Therefore, the epidemiological transition provides a potentially powerful framework for understanding the disease patterns and the mortality in populations, as a result of socioeconomic and demographic developments (Omran, 1971). • The epidemiological transition comprises five major successive stages; 1) pestilence and famine, 2) receding pandemic, 3) degenerative and man-made disease, 4) delayed degenerative disease and 5) re-emergence of previous infectious diseases. CVD Epidemiology

  7. The Epidemiological Transition CVD Epidemiology

  8. Major Risk Factor Contributed to CVDs Occurence CVD Epidemiology

  9. Public Health Significance • 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) • Nearly 30% of all disability cases • A major impact on life expectancy • Contributes to deterioration of the quality of life • Leading cause of mortality in developed countries and a rising tendency in developing countries (disease of civilization) CVD Epidemiology

  10. Major risk factors fac swhich re XCONTRIBUTED O CVD • Globalisation • Urbanisation • Ageing • Income • Education • Housing • Access to healthcare & preventative services • Social determinants and drivers • Behavioural risk factors • Unhealthy diet • Tobacco use • Physical inactivity • Harmful usGlobalisation • Urbanisation • Ageing • Income • Education • Housing • Access to healthcare & preventative services • Social determinants and drivers • Behavioural risk factors • Unhealthy diet • Tobacco use • Physical inactivity • Harmful use of Alcohol • Hypertension • Diabetes • Raised blood lipids • Obesity • Metabolicriskfactors • Cardiovascular disease • Heart attack • Stroke • Heart failure • This figure is adapted from WHO (WHO-HTN, 2013). • e of Alcohol • Hypertension • Diabetes • Raised blood lipids • Obesity • Metabolicriskfactors • Cardiovascular disease • Heart attack • Stroke • Heart failure • This figure is adapted from WHO (WHO-HTN, 2013). CVD Epidemiology

  11. Mujor risk factors fac swhich re XCONTRIBUTED O CVD..co • Stage • Life expectancy at birth • Dominant causes of death % • Examples for the stage • Pestilence and famine • Characterised by high and fluctuating death due to war famines, epidemics and low living conditions • between 20-40 years • Infectious, parasitic diseases and maternal and perinatal mortality. • CVD responsible about < 10 % of death • Mainly in developing countries (Omran, 1971, Mayosi et al., 2005, Carapetis et al., 2006, Maguire, 2006, Watkins et al., 2009) • Receding pandemic • Rapid improvement of sanitation, health and nutrition. • around 55 years • Infectious disease. • NCDs start to increase progressively • USA in early 20th century and parts of China and India today (Omran, 1971, Olshansky and Ault, 1986, Gazaino, 2008) • Degenerative and man-made diseases • Improvements in socioeconomic status and urbanisation, leading to behavioural risk changes notably poor dietary habits, tobacco use and low physical activity. • > 70 years; • NCDs, particularly CVDs, are responsible for 35-65% of all deaths • USA during 1930-1965, Western Europe 10 years later, Middle East, parts of China, Eastern Europe and Latin America today (Omran, 1971, Critchley et al., 2004, Gaziano, 2005, Gazaino, 2008) • Delayed degenerative diseases • During which, distinctly rapid declines in mortality rate takes place. • 80-85 years • CVDs, cancer, coronary heart disease, ischemic stroke, and more recently congestive heart failure • Examples for this stage are Canada and USA where the CVD mortality rates is lower than the rest of world (Omran, 1971, Olshansky and Ault, 1986, Sheth et al., 1999, Alberti et al., 2006). • Re-emergence of previous infectious diseases. • Re-emergence of previous infectious diseases (malaria, tuberculosis, cholera, plague), and emergence of new diseases. This stage witnesses increased prosperity, urbanisation, new therapeutic advances, and epidemic of obesity, DM and HTN. • 80-85 years • CVDs, cancer, coronary heart disease, ischemic stroke, and more recently congestive heart failure • Examples are in USA during the last 4 decades where the mortality has annually decreased by 2% for heart disease and 3 % for stroke. In England and Wales, the coronary heart disease had declined by 62% in men and 42 % in women of 25-84 years old between the years of 1981-2000 (Rogers and Hackenberg, 1987, Omran, 1998, Unal et al., 2004, Ford et al., 2007). CVD Epidemiology

  12. The epidemiological transition • riginally, Omran (1971) defines the ‘Epidemiological Transition’ • as shifts in recorded cause of deaths from CD to NCD. Therefore, the epidemiological transition provides a potentially powerful framework for understanding the disease patterns and the mortality in populations, as a result of socioeconomic and demographic developments (Omran, 1971). The epidemiological transition comprises five major successive stages; 1) pestilence and famine, 2) receding pandemic, 3) degenerative and man-made disease, 4) delayed degenerative disease and 5) re-emergence of previous infectious diseases. Each stage has its own characteristics in terms of predominant causes of death, life expectancy at birth, examples for each stage, as illustrated in (Table 2) (Omran, 1971, Olshansky and Ault, 1986, Yusuf et al., 2001a, Gazaino, 2008). CVD Epidemiology

  13. Types of Cardiovascular Diseases • Congenital heart disease • Rheumatic heart disease (streptococcal infection) • Hypertensive heart disease • Coronary heart disease (ischemic heart disease [IHD], heart attack, myocardial infarction, angina pectoris) • Cerebrovascular disease (stroke, transient ischemic attack [TIA] ) • Peripheral vascular disease • Heart failure • Cardiomyopathies CVD Epidemiology

  14. Disciplines of CVD Epidemiology • Descriptive epidemiology: • Describing distribution of cardiovascular disease by PERSON (i.e., age, gender, ethnicity) TIME and PLACE • Analytic epidemiology • Analyzing relationships between CVD and risk factors (which increase the probability of disease occurrence at population level), risk models, multicausal developments • Experimental epidemiology/Interventions • Strategies of CVD prevention (primordial, primary, secondary, tertiary; individual vscommunity levels) CVD Epidemiology

  15. Descriptive CVD Epidemiology

  16. Descriptive Epidemiology I. Distribution Patterns in the World • CVD deaths account for one third of all deaths (50% attributed to coronary deaths) • Developed countries: decreasing tendencies (e.g, USA, Sweden), attributed to: improvement of lifestyle factors, decrease of tobacco use, higher level of health consciousness, better diagnostic and therapeutic procedures • Developing countries: increasing tendencies due to increasing longevity, urbanization, western type lifestyle CVD Epidemiology

  17. Descriptive Epidemiology II. AGE • Early lesions of blood vessel, atherosclerotic plaques: around 20 years - adult lifestyle patterns usually start in childhood and youth (tobacco use, 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 CVD Epidemiology

  18. 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% CVD Epidemiology 1-24 yrs 25-64 yrs >65 yrs

  19. 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% CVD Epidemiology 0% 1-24 yrs 25-64 yrs >65 yrs

  20. The main underlying pathological process that causes CVDs, like CHD and cerebrovascular stroke, is known as atherosclerosis. • Poor lifestyle habits and ClinCVRFs are primary causes of most atherosclerotic processes. However, substantial evidence describes atherosclerosis as an • inflammatory process affecting medium-large blood vessels throughout the cardiovascular system (Ross, 1999, Anand et al., 2000, Anand et al., 2001, Davis, 2005). When the endothelium of the blood vessel is exposed to high levels of Low density lipoprotein – cholesterol(LDL-C) and other ingredients such as free radicals, these affect the • permeability of the endothelium, • resulting in lymphocytes and monocytes migrating into deeper layers of Atherosclerosis CVD Epidemiology

  21. The main underlying pathological process that causes CVDs, like CHD and cerebrovascular stroke, is known as atherosclerosis. Poor lifestyle habits and ClinCVRFs are primary causes of most atherosclerotic processes. However, substantial evidence describes atherosclerosis as an inflammatory process affecting medium-large blood vessels throughout the cardiovascular system (Ross, 1999, Anand et al., 2000, Anand et al., 2001, Davis, 2005). When the endothelium of the blood vessel is exposed to high levels of Low density lipoprotein – cholesterol(LDL-C) and other ingredients such as free radicals, these affect the permeability of the endothelium, resulting in lymphocytes and monocytes migrating into deeper layers of The main underlying pathological process that causes CVDs, like CHD and cerebrovascular stroke, is known as atherosclerosis. Poor lifestyle habits and ClinCVRFs are primary causes of most atherosclerotic processes. However, substantial evidence describes atherosclerosis as an inflammatory process affecting medium-large blood vessels throughout the cardiovascular system (Ross, 1999, Anand et al., 2000, Anand et al., 2001, Davis, 2005). When the endothelium of the blood vessel is exposed to high levels of Low density lipoprotein – cholesterol(LDL-C) and other ingredients such as free radicals, these affect the permeability of the endothelium, resulting in lymphocytes and monocytes migrating into deeper layers of CVD Epidemiology

  22. Descriptive Epidemiology III. SEX • 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, but at an older age • Women: special case (WHO reports) • Higher risk in women than men (tobacco use, high triglyceride levels) • Higher prevalence of certain risk factors in women (diabetes mellitus, depression) • Gender-specific risk factors (risks for women only: use of oral contraceptives, hormone replacement therapy, polycystic ovary syndrome, etc) CVD Epidemiology

  23. Descriptive Epidemiology IV. ETHNICITY • In the US: increased CVD deaths among African-American and South-Asian populations in comparison with Whites • Increased stroke risk in African-American, some Hispanic American, Chinese, and Japanese populations • Migration: 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 (migrant studies) CVD Epidemiology

  24. Analytical CVD Epidemiology

  25. Analytic Epidemiology I.Role of Risk Factors • Over 300 risk factors have been associated with coronary heart disease, hypertension and stroke • About 75% of CVD can be attributed to conventional risk factors • Risk factors of great public health significance: • High prevalence in many populations • Great independent impact on CVD risk • Their control and treatment result in reduced CVD risk • Developing countries: double burden of risks (problems of undernutrition and infections in addition to CVD risks) CVD Epidemiology

  26. Analytic Epidemiology II.Classification of Risk Factors CVD Epidemiology

  27. Analytic Epidemiology III. Hypertension • Systolic blood pressure >140 Hgmm and/or a diastolic blood pressure > 90 Hgmm • Free of clinical symptoms for many years (screening) • In most countries, up to 30 percent of adults suffer from hypertension • Positive family history • Dietary habits (a high intake of salt, processed food, low levels of water hardness, high thyramine content of food, alcohol use) • Modern lifestyle (increased sympathetic activity, psychosocial and occupational stressors) CVD Epidemiology

  28. Analytic Epidemiology IV.Rheumatic Fever andRheumatic Heart Disease • Development: Rheumatic fever usually follows an untreated beta-haemolytic streptococcal (GABS) throatinfection in children • As a consequence, some heart valves (e.g. mitral, tricuspid) may be permanently damaged, which may progress to heart failure • Today mostly affects children in developing countries, linked to poverty, inadequacy of health care access • Occurrence: 12 million people are currently estimated to suffer from rheumatic fever and RHD, of whom two-thirds are children (5-15 years) CVD Epidemiology

  29. Analytic Epidemiology V. Abnormal Blood Lipids • Serum cholesterol: structure and functioning of blood vessels, atherosclerotic plaques • Altering functions of cholesterol fractions (LDL: risk, HDL: protection) • Estrogen: tends to raise HDL-cholesterol and lower LDL-cholesterol, which provides protection for women during their reproductive age (15-49 years) • Partially genetic determination of metabolism, partially dependent of nutrition (eggs, meats, dairy products) CVD Epidemiology

  30. Current Recommended Lipid Levels CVD Epidemiology

  31. Analytic Epidemiology VI. Tobacco Use • The link between smoking and CVD (mainly CHD) was identified in 1940 • Greatest risk: initiation during adolescence (< 16 years) • Passive smoking: additional risk • Women smokers: are at higher risk of CHD and CVD than male smokers • Several mechanisms: damages the endothelium lining, increases atherosclerotic plaques, raises LDL and lowers HDL, promotes artery spasms, raises oxygen demand of cardiac muscles • Nicotine accelerates the heart rate and raises blood pressure CVD Epidemiology

  32. Analytic Epidemiology VII. Physical Inactivity • Regular physical activity: protective factor • Physical activity: helps reduce stress, anxiety and depression • Intensity and duration (150 minutes/week [intermediate] or 60 minutes/week [heavy] ) • Modernization, urbanization, mechanized transport: sedentary lifestyle (60% of global population) • Raises CVD risk and also the development of other risk factors (glucose metabolism, diabetes mellitus, blood coagulation, obesity, high blood pressure, worsening lipid profile) CVD Epidemiology

  33. Analytic Epidemiology VIII.Unhealthy Diet, Obesity, Diabetes • Unhealthy diet: low fruits, vegetables, fiber content; high saturated fat intake, refined sugar • Body Mass Index (BMI): > 25: overweight; > 30: obesity • A modern ”epidemic”: more than 60% of adults in the US are overweight or obese, in China: 70 million overweight people • Increases the risk of both CVD and diabetes mellitus • Diabetes mellitus: damages both peripheral and coronary blood vessels (micro-angiopathies) CVD Epidemiology

  34. Analytic EpidemiologyIX. Psycho-social factors • Psychological factors (Type A behavior, hostility) • Depression and CVD: bidirectional link • depression may increase the risk of CVD and worsen recovery process • CVD may induce depression • Low socioeconomic status (SES): • In developed countries: less educated and lower SES groups (accumulation of risk factors) • In developing countries: more educated and higher SES groups (western lifestyle) CVD Epidemiology

  35. CVD Prevention (Interventional CVD Epidemiology)

  36. Levels of CVD Prevention -I • Primordial:social, legal and other (often nonmedical) activities which may lead to lowering of risk factors (e.g. socioeconomic development, smoke-free public places) • Primary:controlling risk factors contributing to CVD (health education programs, tobacco prevention campaigns, sports programs, nutrition counselling, regular check-up of blood pressure / certain blood parameters, e.g. blood lipids including cholesterol, glucose, etc) CVD Epidemiology

  37. Levels of CVD Prevention - II • Secondary:early detection by screening / setting up personal risk profile;proper managementof symptomatic patients • Tertiary:CVDrehabilitation (e.g. for stroke, paralysis patients); prevention of CVD recurrence (CVD patients have a 5-7 times higher risk of a new heart attack) CVD Epidemiology

  38. CVD Prevention Approaches • Primordial prevention involves the prevention of risk factors which may cause CVD, thereby reducing the likelihood CVD development • Primary prevention involves prevention of onset of disease in persons without symptoms • Secondary prevention refers to the prevention of death or recurrence of disease in those who are already symptomatic CVD Epidemiology

  39. Risk Factor Concepts in Primary Prevention • Non-modifiable risk factors (e.g. age, sex, race, and family history of CVD) identify high-risk populations • Behavioral(modifiable) risk factors (e.g. sedentary lifestyle, unhealthy diet, tobacco or alcohol use, physical inactivity) • Physiological risk factors (e.g. hypertension, obesity, lipid problems, and diabetes) may be a consequence of behavioral risk factors CVD Epidemiology

  40. Cardiovascular Prevention - III • The population-wide approach:targetingthe whole population: includes tobacco prevention programs, salt and refined sugar restriction, promoting high fiber – low fat diets, etc. • The individual approach:detecting those at greatest risk: includes targeting lifestyle guidelines, e.g. tobacco cessation programs CVD Epidemiology

  41. Cardiovascular Prevention - IV Examplesof community-wide CVD prevention programs: • Framingham Heart Study & Risk Scoring(1948-), USA • North-Karelia Project (1972-), Finland • Stanford Projects (1972-75, 1980-86), USA • Multiple Risk factor Intervention Trial (1972-79), USA • Minnesota Cardiovascular Health Program (1980-88), USA CVD Epidemiology

  42. References • Newschaffer CJ, Longjian L, Sim L. Cardiovascular disease. In: Remington PL, Brownson RC, Wegner MV. Chronic disease epidemiology and control. 3rd edition. Washington DC: American Public Health Association, 2010. • Piko B. Epidemiology of cardiovascular diseases. University of Pittsburgh. • Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497. • Werner et al. Canadian Journal of Cardiology 1998; 14(Suppl) B:3B-10B CVD Epidemiology

  43. Thank you for your kind attention CVD Epidemiology

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