Epidemic of Cardiovascular disease Global and US trends Any Lessons for Honduras?

1. Epidemic of Cardiovascular disease Global and US trendsAny Lessons for Honduras? Dr. Thomas G. Allison Cardiovascular Diseases and Internal Medicine Mayo Clinic Rochester, MN

2. Disclosures • Conflicts of interest: none • Off-label use of drugs or devices: none

3. Developing countries • 80% of worldwide CV deaths • Occur at a younger age • 2010 – 70% of the elderly will live in the developing world Global Burden of Cardiovascular Disease Total deaths – 57 million 2002 statistics Cardiovascular HIV TB Malaria 16.7 million 5 million Lopez. Lancet 2006; Reddy. NEJM 2004

4. International Comparison (Men ages 35-74)

5. Cardiovascular Disease in the Americas

7. Lowest Highest

8. Haiti: 55 years Guyana: 63 years Bolivia: 65 years Honduras: 67 years Brazil: 70 years Peru: 71 years Jamaica: 72 years Paraguay: 72 years Columbia: 73 years Mexico: 74 years Argentina: 75 years Uruguay: 75 years Panama: 76 years Costa Rica: 77 years Chile: 77 years Cuba: 78 years USA: 78 years Canada: 80 years Life Expectancy in the Americas

9. Modified Model of the Epidemiological Transition as it Pertains to Cardiovascular Disease Yusef et al. Circulation 2001;104:276-2753

10. Stage 1: Age of Pestilence and Famine

11. Stage 1: Haiti Life expectancy = 55 years

12. Causes of Death Haiti 2002

13. Stage 2: Age of Receding Pandemics

14. Stage 2: Bolivia Life expectancy = 65 years

15. Causes of Death Bolivia 2002

16. Stage 3: Age of Degenerative and Man-Made Diseases

17. Stage 3: Jamaica Life expectancy = 72 years

18. Causes of Death Jamaica 2002

19. Unknown Injury Other non-communicable diseases Chronic obstructive pulmonary disease Cerebro-cardiovascular disease Cancer Maternal and perinatal conditions Communicable diseases Proportion of deaths (%) Year Changing Distribution of the Causes ofDeath in Peoples Republic of China Yang. Lancet, 2008

21. Stage 4: Age of Delayed Degenerative Diseases

22. Causes of Death USA 2002

24. Age-adjusted US CVD Disease Trends Years 1996-2004 Nemetz et al. Arch Intern Med 2008;163:264-270 • Despite decrease in Heart Disease Mortality • Heart disease remains highly prevalent • #1 Cause of death in US • #1 Contributor to US health care costs

25. Hospital discharges for cardiovascular diseases. (United States: 1970-2006). Note: Hospital discharges include people discharged alive, dead and status unknown. Source: NCHS and NHLBI.

26. Total Cost = 344.9 billion dollars Estimated direct and indirect costs (in billions of dollars) of major cardiovascular diseases and stroke (United States: 2009). Source: NHLBI.

27. Transition Factors 1 → 2 Population growth Older population Sanitation – water quality Immunization Antibiotics Increased mechanization of food production More processed food Increased salt intake Hypertension Hypertensive heart disease Hemorrhagic stroke

28. Transition Factors 2 → 3 Changing economy Affluence Mass media Cigarette smoking Reduced physical activity Increased caloric intake More meat consumption Obesity Diabetes Hyperlipidemia Ischemic Stroke MI

29. Incubation Period for Chronic Disease

30. Transition Factors 3 → 4 More educated public Increased spending on medical care Secondary prevention practices Primary prevention practices Improved survival from MI Reduced MI, stroke at young ages

31. CHD Trends McGovern et al, Circulation 2001;104:19-24

32. Pre-1985 due largely to lifestyle changes Smoking cessation 59%  25% Decreased dietary fat intake Increased leisure-time physical activity Post-1985 due largely to medical management Coronary care units Electrical defibrillators Thrombolysis Emergent angioplasty Medical Rx Aspirin, beta-blockers, ACE-inhibitors, statins Reduction in CVD Death Rate in US [Primary Prevention] [Secondary Prevention] McGovern et al. Circulation 2001;104:19-24

33. CAD Prevalence in Patients Who Died of UnnaturalCauses in Olmsted County, MN and Had Autopsy Nemetz et al. Arch Intern Med 2008;168:264-270

34. Causes of Death Honduras versus USWhere is Honduras in the Epidemiologic Transition? Source: Death and Daly estimates by cause, 2002 http://www.who.int/entity/healthinfo/statistics/bodfbddeathdalyestimates.xls

35. Causes of Death Honduras 2002

36. Honduras versus US Statistics • Life expectancy at birth • Honduras: M = 67/F = 73 US: M = 75/F = 80 • Healthy life expectancy at birth • Honduras: M = 56/F = 61 US: M = 67/F = 71 • Probability of dying between 15-60 years • Honduras: M = 22.9%/F = 13.3% • US: M = 13.7%/F = 8.0%

37. Honduras versus US Statistics • Total expenditure on health per capita • Honduras: $241 US: $6,714 • Gross national income per capita • Honduras: $3,240 US: $44,070 • Total expenditure on health as % of GDP • Honduras: 7.4% US: 15.3% World Health Statistics 2008 Financial data from 2006

38. Risk Factors in Honduras • No data on hyperlipidemia for Honduras • Hypertension highly prevalent throughout Latin American and Caribbean • No specific figures for Honduras • Greater for persons of African descent • 1 survey on diabetes in Tegucigalpa • Prevalence 7.8%; 42% unrecognized • 1 survey 2005-6 on females aged 15-49 for tobacco use and obesity • Urban > rural for both • Tobacco use 3.7 versus 0.6% • Obesity 23 versus 14%

39. Risk Factors, Honduras

40. Risk Factors, Honduras

41. Conclusions • Honduras is moving into the age of man-made and degenerative diseases • All risk factors will be increasing • Honduras may not afford US high-tech strategies for CVD prevention

42. $5,000 USD $93,000 USD In US we treat coronary disease with devices $26,000 USD

43. $19.95 USD $8.09 USD $5.95 USD Some less expensive devices to treat coronary disease

44. Greetings from Rochester, MN (winter)

45. Comments? • Questions?