Prevention of Cardiovascular Diseases: Begin in Childhood!

1. Prevention of Cardiovascular Diseases: Begin in Childhood! Ruth Collins-Nakai MD, MBA, FRCPC, FACC President InterAmerican Society of Cardiology

3. Outline • World status of CVDs • Argentinean status of CVDs • Prevention efficacy • Recommendations re risk factors • Role of CV specialist in prevention

4. World Status of CVD • Represents 30% of all deaths worldwide (15 million deaths/year) • Leading cause of death and disability • CVD burden  in developing countries • Risk factors  worldwide 1999 WHF "Impending Global Pandemic of CVDs

5. % GDP spent on health

6. Population per Physician http://cvdinfobase.ic.gc.ca

7. http://cvdinfobase.ic.gc.ca

8. Argentina CVD mortality: females http://cvdinfobase.ic.gc.ca

9. Argentina CVD mortality: females

10. Argentina IHD mortality: males http://cvdinfobase.ig.gc.ca

11. Argentina Diabetes: females males http://cvdinfobase.ic.gc.ca

12. Atherosclerosis: A Systemic Disease

13. Prevention Facts • Defined Risk Factors in adults associated with accelerated atherosclerosis and CVD rates* • Atherosclerosis begins in childhood * * • Extent of atherosclerosis in children correlated with same risk factors as in adults * * * *Strong JP et al JAMA 1999;281:727-735 * Berenson GS et al NEJM 1998;338:1650-1656 * * *Williams CL et al Circ. 2002;106:143-160

15. 80 60 40 20 0 Early Appearance of Atherosclerosis: Bogalusa Heart Study Prevalence of Fibrous Plaque Lesions 80 Aorta Coronary Arteries 60 % 40 20 0 2-15 16-20 21-25 26-39 2-15 16-20 21-25 26-39 Age (Years) p = 0.001 for trend toward increasing prevalence with age in aorta and coronary arteries.

16. The Evidence • physical activity associated with  life expectancy • Direct association between obesity & insulin resistance in children • Direct association between obesity & lipid levels in children • Tracking: BMI>weight>skinfold thicknesses>lipids>BP • Clusters of multiple risk factors persist strongly from child-to-adulthood

17. Risk Factors for Atherosclerosis • Smoking • Obesity • High blood pressure • Physical Inactivity • High blood fat levels • Diabetes • Positive family history • Other (ethnicity, anger)

18. Effect of Multiple Risk Factors on Probability of CAD: Framingham Study 40 21 10-Year % Probability of Event 14 10 6 4 SBP 150-160 + + + + + + Cholesterol 6.2-6.8 - + + + + +HDL-C 0.8-0.9 - - + + + +Diabetes - - - + + + Cigarettes - - - - + + ECG-LVH - - - - - +

19. Recommendations • Cardiovascular Health in Childhood (AHA Scientific Statement) • Circ 2002;106:143-160 • Circ 2002;107:1562-1566 • Canadian Cardiovascular Society Consensus Conference on Prevention of CVD: The Role of the CV Specialist • CJC 1999;15(supple.G)

20. Smoking

21. Tobacco • Complete cessation for those who smoke • No exposure to environmental tobacco smoke • No new initiation of cigarette smoking or tobacco use

22. Obesity • Appropriate body weight (BMI for age) (www.cdc.gov/growthcharts./) • Overall healthy eating pattern (limit salt, fat, calories & sugar > 2 years age) • Balance “Energy in = energy out” for weight • Begin treatment before adolescence

24. Trends in prevalence of overweight in USA (CDC – NHANES) % 1963-70 1971-74 1976-80 1988-94 1999 6-11 yrs 12-19 yrs

25. Physical Activity • Physical activity every day (60 minutes per day for children) • Reduce/limit sedentary time (e.g.. TV maximum 2 hours per day) • May add resistance training to aerobic activity in adolescents

26. Lipids & Lipoproteins • Total cholesterol <4.4 mmol/L recommended (USA>170mg/dL borderline; >200 mg/dL is ) • LDL-C <2.85 mmol/L recommended (USA<110mg/dL) • Triglycerides <1.5 mmol/L recommended (USA <150 mg/dL) • HDL-C >35 mg/dL recommended

29. Effect of SBP and DBP onAge-Adjusted CAD Mortality: MRFIT CAD Death Rate per 10,000 Person-years 80.6 48.3 43.8 38.1 37.4 34.7 31.0 25.3 25.8 25.2 24.9 24.6 23.8 160+ 16.9 13.9 12.6 12.8 11.8 20.6 140-159 10.3 11.8 8.8 8.5 9.2 120-139 <120 100+ 90-99 80-89 75-79 70-74 <70 Systolic BP (mmHg) Diastolic BP (mmHg)

30. Blood Pressure • Systolic & diastolic BP>90th% for age, sex and height is abnormal (www.nhlbi.nih.gov/health/prof/heart/hbp/hbp_ped.htm.) • >130/~80 is almost always pathological in youth. • Use proven effective therapies recommended for adults (CPGs)

31. Diabetes • Adequate nutrition (neither over nor undernutrition) of pregnant women: Barker hypothesis • Limit sugar intake • Maintain normal weight for age & height • For type 1 diabetics, ongoing strict control (Hgb A1c)

32. Other Risk Factors • Ethnicity (esp. South Asian / aboriginal/black/Hispanic) • Low socioeconomic level • Social isolation • Depression • Pregnancy (HTN and gestnl diabetes) • “Emerging” risk factors

33. Childhood Abuse • Adverse childhood experiences (ACEs) • 1.7x  risk with emotional abuse • 1.7x  risk with crime in household • 1.3x  risk with emotional neglect • 1.3x  risk with substance abuse • Depressed affect OR 2.1 • Anger: OR 2.5 • 7 or > ACEs  risk almost 4x Dong M et al CIRC 110; 2004

34. Specialized medicine Hyper First line medicine High Risk Low Primary prevention Secondary prevention Clinical Application of the Concept of Risk - Vascular, unstable Pluri-vascular Diabetic + risk factors Diabetic Vascular Asymptomatic + risk factors Asymptomatic Symptomatic

35. Economic Burden of Coronary Artery Disease (CAD) Direct and Indirect Cost of CADCountry (not adjusted for inflation) US (2000) $118.2 billion USD Canada (1993) $19.6 billion CDN (15.2% of total economic burden of illness) UK (1996) £10 billion Germany (1996) 112 billion DM Taiwan (1991) 9.0-11.9 billion new Taiwan $ Sweden (1994) 276 billion SEK

36. BMI <75%ile 75-85%ile 85-95%ile at risk for ow >95%ile overweight Reaffirm healthy Habits; f/u annually Assess family history, food habits, activity Council to change food intake; increase physical activity Council to change food intake; increase physical activity Assess RF; If >1 RF, treat as >95%ile Assess RF; Treat RFs; Involve family Nesbitt SD et al Ethnicity & Disease 14;2004

37. Role of Cardiovascular Specialist • Education of other health care personnel • Advocate for heart healthy public policies • Treat individual patients, including children with significant risk factors.

39. Conclusions • The burden of global CVD is increasing • The burden of risk factors is rising alarmingly in children and youth • Cardiovascular specialists have an obligation to lead in prevention • Educate, Advocate, Treat

40. Gracias!

42. Questions for readers of Prevention of Cardiovascular Diseases: Begin in Childhood! lecture by Ruth Collins-Nakai(developed by Supercourse Team) At what age do we begin to see fatty streaks associated with atherosclerosis? What is the difference in risk from the lowest to highest risk factors Why should we intervene with children to prevent MIs 60 years later?