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An Ounce of Prevention Is Worth a Pound of Cure

Darrell Sneed, MD Cardiology Grand Rounds University of Kentucky April 29, 2010. An Ounce of Prevention Is Worth a Pound of Cure. Leading Causes of Worldwide Death. The World Health Report 2002 WHO, 2002. Leading Causes of Death in the US. Males. Females. 409,867. 454,613. 268,890.

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An Ounce of Prevention Is Worth a Pound of Cure

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  1. Darrell Sneed, MD Cardiology Grand Rounds University of Kentucky April 29, 2010 An Ounce of Prevention Is Worth a Pound of Cure

  2. Leading Causes of Worldwide Death The World Health Report 2002 WHO, 2002

  3. Leading Causes of Death in the US Males Females 409,867 454,613 268,890 290,422 Heart Disease and Stroke Statistics — 2009 Update

  4. What is Cardiovascular Disease? • Coronary Heart Disease 52% • Stroke 17% • Heart Failure 7% • Hypertension 7% • Diseases of the Arteries 4% • Other 14% Heart Disease and Stroke Statistics — 2009 Update

  5. Death from Diseases of the Heart, 2006 KY 235.5/100,000 (#5) US 200.2/100,000 www.statehealthfacts.org

  6. Kentucky Data CVD is the leading cause of death in Kentucky and accounted for 35% of all deaths in 2005 Age-adjusted death rate per 100,000 CauseKY US CVD 324 (#46) 278 CHD 161 (#43) 144 Stroke 51 (#36) 47 Heart Disease and Stroke Statistics — 2009 Update

  7. Death from Diseases of the Heart, 2003 http://www.ca.uky.edu/hes/?p=6

  8. Leading Causes of Hospitalization Heart Disease and Stroke Statistics — 2009 Update

  9. US Estimated Costs in 2009 $345 Billion Heart Disease and Stroke Statistics — 2009 Update

  10. What are the Risk Factors? • Age • Family History (<55 for ♂ and <65 for ♀) • Diabetes • Dyslipidemia • Hypertension • Overweight & Obesity • Physical Inactivity • Tobacco Use • Psychosocial distress

  11. ModifiableRisk Factors • Diabetes • Dyslipidemia • Hypertension • Overweight & Obesity • Physical Inactivity • Tobacco Use • Psychosocial distress

  12. Prevalence of Atherosclerosis in Young Adults The Bogalusa Heart Study 10 8 Intimal-Surface Involvement (%) 6 4 2 0 0 RF 1 RF 2 RF 3-4 RF NS Smoker Coronary Artery Fibrous Plaques Berenson G, NEJM, 1998

  13. None CVD Risk Increases with Increasing Risk Factors Additive Effects of HTN, HL, and Smoking 140 No DM 120 DM 100 80 Age-adjusted CVD death rate Per 10,000 person years 60 40 20 0 One Three Two Number of Risk Factors Stamler, Diabetes Care, 1993

  14. Prevalence of Atherosclerosis Prevalence (%) 75% 66% 21% Age (Years) Tuzcu EM, Circulation, 2001

  15. Prevention • 2003 Behavioral Risk Factor Surveillance System Survey Kentucky had the highest prevalence of multiple risk factors for heart disease in adults (46.2%) among the fifty states • Surveyed risk factors • High blood pressure • High cholesterol • Diabetes • Current smoking • Physical inactivity • Obesity Morb Mortal Wkly Rep 2005

  16. INTERHEART: 9 Modifiable risk factors & first-MI 100 90 80 60 50 PAR (%) 36 33 40 20 18 20 12 14 10 7 0 Hyper-tension Smoking Fruits/veg Exercise Alcohol Abdominal obesity Psycho-social Lipids All 9 risk factors Diabetes N = 15,152 patients and 14,820 controls in 52 countries PAR = population attributable risk, adjusted for all risk factors Yusuf S et al. Lancet. 2004

  17. Lifestyle Affects More than CVD Risk • Multiple Risk Factors are associated with: • Increased CVD Events • Increased All-Cause & CVD Mortality • Increased Disability • Increased Health Care Costs • Decreased Socioeconomic Status • Decreased Quality of Life Morb Mortal Wkly Rep 2005

  18. ModifiableRisk Factors • Diabetes • Dyslipidemia • Hypertension • Overweight & Obesity • Physical Inactivity • Tobacco Use • Psychosocial distress

  19. Diabetes • Fasting glucose >126 • Estimated 15 million Americans are diagnosed with diabetes • Another 5 million are diabetic but unaware • Another 14.7 million have pre-diabetes (glucose 110-126) • At least 65 percent of people with diabetes die of some form of heart or blood vessel disease Heart Disease and Stroke Statistics — 2009 Update

  20. Prevalence of Diabetes 2008 KY 9.8% (#9) US 8.2% www.statehealthfacts.org

  21. DM & CHD: 7-Year Risk of MI Nondiabetic Diabetic Haffner S, NEJM, 1998

  22. Total CVD CHD Cardiac failure Intermittent claudication CVA Diabetes Mellitus: Risk of CVD Events Framingham Heart Study: 30 year follow-up Men Women 10 8 6 Risk ratio 4 2 0 Age-adjusted Annual Rate/1000 Wilson P, Hyperglycemia Diabetes and Vascular Disease, 1992

  23. Lifestyle Changes Lower Progression to DM 522 overweight patients with impaired fasting glucose randomized to intervention or usual care for 3 years Finnish Diabetes Prevention Study Intervention 30% Usual Care 23% 20% 11% 10% 0 % with Diabetes Intervention: Weight reduction (>5%), reduction of total fat (<30%) and saturated fat (<10%), increased fiber (>15g/1000 cal) and exercise (at least 30 min/daily) Tuomilehto J, NEJM, 2001

  24. ModifiableRisk Factors • Diabetes • Dyslipidemia • Hypertension • Overweight & Obesity • Physical Inactivity • Tobacco Use • Psychosocial distress

  25. Lipids • Total cholesterol • <200 desirable, >240 “high” • Low-density lipoprotein (LDL) • Optimum <100 mg/dL • <70 mg/dL if CVD • High-density lipoprotein (HDL) • >40 mg/dL in ♂ • >50 mg/dL in ♀ • Triglycerides • <150 mg/dL Heart Disease and Stroke Statistics — 2009 Update

  26. Relative Risk for CHD 3.7 2.9 2.2 1.7 1.3 1.0 40 70 100 130 160 190 LDL-C, mg/dL Increased CVD Risk with Increasing LDL Grundy SM, Circulation, 2004

  27. Low HDL and High LDL Increase Risk Framingham Heart Study Relative Risk of CHD HDL mg/dL LDL, mg/dL Castelli, CanJ Cardiol, 1988

  28. Statins: Primary Prevention Relationship between LDL-C Levels and Event Rates in Primary Prevention Trials 10 Statin Placebo 8 WOSCOPS 6 WOSCOPS AFCAPS Event (%) 4 AFCAPS ASCOT ASCOT 2 JUPITER 0 JUPITER –1 75 95 115 135 155 175 195 55 LDL-C (mg/dL) O’Keefe JH ,JACC, 2004; Ridker, NEJM, 2008

  29. ModifiableRisk Factors • Diabetes • Dyslipidemia • Hypertension • Overweight & Obesity • Physical Inactivity • Tobacco Use • Psychosocial distress

  30. Hypertension • Hypertension • >140/90 • >130/80 in DM or CKD • 1 in 3 US Adults has hypertension • 79% are aware of the hypertension • 69% are under treatment Heart Disease and Stroke Statistics — 2009 Update

  31. RR = X8 175/105 RR = X4 Increasing Cardiovascular Mortality Risk 155/95 RR = X2 RR = X1 135/85 115/75 SBP/DBP, mm Hg CV Mortality Increases with Increased BP 1 Million Individuals, aged 40 to 69 years Lewington S et al. Lancet. 2002

  32. Small Changes Have a Large Impact • 1 million adults 7% reduction in risk of IHD* mortality 2 mm Hg decrease in mean SBP 10% reduction in risk of stroke mortality 32 Lewington S, Lancet, 2002

  33. Salt Reduction Alone Reduces CV Events Bibbins-Domingo, NEJM 2010

  34. Projected Estimate on Annunal CVD Incidence Bibbins-Domingo, NEJM 2010

  35. BP Control Usually Requires Combo Therapy Most patients require 2 antihypertensives to reach BP goal Trial/SBP Achieved Copley JB, Dis Mon, 2005; Dahlof B, Lancet, 2005

  36. ModifiableRisk Factors • Diabetes • Dyslipidemia • Hypertension • Overweight & Obesity • Physical Inactivity • Tobacco Use • Psychosocial distress

  37. Overweight & Obesity • BMI optimally ≤25 kg/m2 • Overweight is BMI 25.1-30 • Obese is BMI >30 • Waist >40” in men and >35” in women

  38. Adults Who are Overweight or Obese, 2008 KY 66.8% (#6) US 63% www.statehealthfacts.org

  39. Children Overweight & Obese, 2007 KY 37% (#3) US 32% www.statehealthfacts.org

  40. <18.5 18.6-25.0 25.1-30.0 30.1-35.0 35.1-40.0 >40.0 BMI and Age of First NSTEMI 95 Men Women 84 73 Age 62 51 40 Body Mass index (kg/m2) Madala M, JACC, 2008

  41. <22 <23 23 - 23.9 24 - 24.9 25 - 26.9 27 - 28.9 29 - 30.9 31 - 32.9 33 - 34.9 35+ Relationship Between BMI and Diabetes Men Women Age-Adjusted Relative Risk Body Mass index (kg/m2) Chan, J. Diabetes Care1994; Colditz,G. Ann Intern Med1995

  42. Relationship Between BMI & Cholesterol 50 50 Females Males 40 40 Percent of Subjects 30 30 20 20 10 10 <18.5 18.5-24.9 25-26.9 27-29.9 >30 <18.5 18.5-24.9 25-26.9 27-29.9 >30 Body Mass Index >25,000 Females Age 30-54 12 year follow-up (1974) Netherlands >23,000 Males Age 30-54 12 year follow-up (1974) Netherlands Seidell, JC,.Arch of InternMed1996

  43. Weight Change and CVD Risk Factor Sum Weight Change During 16-y Follow-up Loss >2.25 kg Gain >2.25 kg +37% +20% Change in Risk Factor Sum (%) -40% -48% Men Women Wilson, PW. Arch Intern Med 1999;159:1104

  44. ModifiableRisk Factors • Diabetes • Dyslipidemia • Hypertension • Overweight & Obesity • Physical Inactivity • Tobacco Use • Psychosocial distress

  45. Definitions • Physical activity • bodily movement produced by skeletal muscle that requires energy expenditure and promotes health benefits • Exercise training • planned, structured, and repetitive bodily movement done to improve or maintain one or more components of physical fitness Mayo Clin Proc. April 2009

  46. Adults Achieving Physical Activity Goals, 2008 KY 44.2% (#6) US 49.2% www.statehealthfacts.org

  47. Cardiorespiratory Fitness & CHD Mortality Rates by Physical Fitness Category in 13334 Healthy People Age-Adjusted Mortality per 10,000 Person-Years 150 Men Women 100 50 0 <6 7 8 9 10 11 12+ METs <21 24.5 28 31.5 35 38.5 42 mL/kg/min Blair S, JAMA, 1989

  48. Exercise Amount • Moderate intensity 150minutes/ week • 3.0- 5.9 METS • Vigorous intensity 75 minutes/ week • ≥6.0 METS • Health benefits • 500- 1000 MET-minutes/ week

  49. Benefits of Exercise • ↑ HDL levels 4.6% • ↓ Triglycerides 3.7% • ↓ LDL 5.0% • ↓ SBP 7.4 mmHg • ↓ DBP 5.8 mmHg • ↓ HgA1c 0.5% to 1%, Thompson PD. Arteriosclerosis, thrombosis and vascular biology, 2003.

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