Epidemiology a nd Prevention of Cardiovascular Diseases

Epidemiology and Prevention of Cardiovascular Diseases

Prof.Dr Selma KARABEY

History • Claudius Galen (A.D.130-200): Elaborated the concept that ‘’the heart is a source of heat and the blood vessels carry pneuma, life-sustaining spirit of the vital organs.’’

History

Andreas Vesalius (1543): Galen’s erroneus teachings were entrenched for 1300 years, until Andreas Vesalius corrected his anatomy.

History

William Harvey (1616): Proposed that the blood circulation is the force of the heart.

The term of cardiovascular diseases

• Coronary heart disease (CHD-Myocardial infarction,angina,coronary insufficiency,coronary death)

• Cerebrovascular disease (Stroke and transient ischemic attacks)

• Peripheral vascular disease• Congestive heart failure • Hypertension• Valvular and congenital heart disease

Definition and classification

Cardiovascular disease:The leading cause of CVD is aterosklerosis, a pathology affecting the walls of large and medium arteries.

Injury and deposits of cholestrol in the wallInflamation and cellular infiltrationCalsificationObstruction of blood flowInadequate perfusion

Definition and classification-3

Coronary Heart Disease:• CHD remains the leading cause of adult death in

industrial societies, although its incidence differs widely.• While deaths from CHD are decreasing in industrialized

nations, they are increasing dramatically in others particularly in the developing world.

• Dynamic national trends in CVD deaths, both upward and downward.

• Rapid changes in CVD risk among migrant populations.

Definition and classification-2

Stroke: Ischaemic stroke:

1)Atherosclerotic stenosis or occlusion2)Cardio-embolism3)Small vessel disease4)Non-atherosclerotic vasculopathies , central nervous system infections (cryptococcus),sickle cell disease, polycythemia

Haemorrhagic stroke:1) Subarachnoid haemorrhages2) Intraparenchymal haemorrhages

Global CVD epidemic• Noncommunicable diseases were responsible for two-thirds of all deaths globally in 2011, up from 60% in 2000. (Cardiovascular diseases, cancers, diabetes and chronic lung diseases)

• Proportion of deaths that are due to NCDs, high-income countries have the highest proportion – 87% of all deaths were caused by NCDs – followed by upper-middle income countries (81%). The proportions are lower in low-income countries (36%) and lower-middle income countries (56%).

Global CVD epidemic-2

• Cardiovascular diseases killed nearly 17 million people in 2011, that is 3 in 10 deaths, of these

7 million people died of ischaemic heart disease and 6.2 million died of stroke. • The number of people who die from CVDs, mainly from heart disease and stroke, will increase to reach 23.3 million by 2030.

(WHO 2013)

3

WHO, The top 10 causes of death, 2011

WHO, The top 10 causes of death , 2011

3

Global Atlas on cardiovascular diseaseprevention and control , WHO, 2011

WHO, The top 10 causes of death ,2011

WHO, The top 10 causes of death 2011,Deaths per 1000 population

Key Messages

•Risk factors of CVDs are similar both for men and women.

•Every year 8.6 million women die from CVDs.

•CVD affects as many women as men.

Global Atlas on cardiovascular diseaseprevention and control , WHO, 2011

Global Atlas on cardiovascular diseaseprevention and control , WHO, 2011

Global Atlas on cardiovascular disease prevention and control , WHO, 2011

Epidemiology of CVD in Turkey

• Cardiovascular diseases are the first death causes, at the national level with 203.457 death in Turkey (47.73% of all causes of death )

• 102.386 men died by the cause of cardiovascular diseases (43.89% of all causes of death )

• 103.071 women died by the cause of cardiovascular diseases (52.27% of all causes of death )

Epidemiology of CVD in Turkey-2

• In Turkey cardiovascular diseases are the primary cause of total burden of disease (DALYs 10,802,494) at the national level , with a ratio of 19.32% (2,086,527 DALYs)

• 20.5% of the total burden of disease in men is caused by cardiovascular diseases.

• 18 % of the total burden of disease in women is caused by cardiovascular diseases.

• (Turkey Cardiovasculer Diseases Prevention and Control Programme 2010-2014)

Incidence Rate (100.000) Prevalence (1000)

Cardiovascular Disease Men MenWomen Women

Cardiovascular Disease

Rheumatic heart disease

Heart disease caused by HT

Acute MI

TotalTotal

Congestive Heart Disease

Cerebrovascular Disease

Long Term Stroke

Angina Pectoris

Inflammatory Heart Disease

Others

Incidence and prevalence of CVD in Turkey

UYH-ME Study, 2004

MEN 233283 Deaths, Turkey, 2004

Cancers

Infection Diseases(Ex.HIV/Aids)

Cardiovascular d.%43

Respiratory System Diseases Maternal and prenatal causes

Injuries

Digestive System Diseases

Diabetes Mellitus %2

Others %5

Türkiye Kalp ve Damar Hastalıklarını Kontrol ve Önleme Programı, 2004

Cancers

%11

Infection Diseases(Ex.HIV/Aids)

Cardiovascular d.

%43

Respiratory System Diseases

Maternal and prenatal causes

Injuries

Digestive System Diseases

Diabetes Mellitus

Women 197177 Deaths,Turkey, 2004

Others

Türkiye Kalp ve Damar Hastalıklarını Kontrol ve Önleme Programı, 2004

Risk Factors of CVD

Global Atlas on cardiovascular diseaseprevention and control , WHO, 2011

Risk Factors of CVD-2

• Age is a powerful cardiovascular risk factor.The rapidly growing burden of CVD in LMICS increases by population ageing.

• According to United Nations(UN) projections, in 2025 there will be 1.2 billion elderly people worldwide with %71 of them likely to be in developing countries.

Key Messages

• Ageing, globalization and urbanization drive the cardiovascular epidemic that is shaped by the rise of behavioural risk factors.

• Unregulated globalization and unplanned urbanization increase the risk of exposure to cardiovascular risk factors and are detrimental to cardiovascular health.

Diet

• Fat: Those blood cholesterol levels were a strong predictor of coronary heart disease in initially healthy populations followed more than 25 years.(Blackburn Q Jacobs 1984)

• Animal fats, specifically saturated fat and cholesterol.

• Carbohydrates: Higher intake of complex carbohydrates, is found with low CHD mortality.

• But a positive association is found between refined sugars and CHD.

• Fruits and vegetables, also contain fiber that decreases the absorption of fat and cholesterol in the intestines.

Alcohol

Alcohol consumption is associated with • increased blood pressure and the risk of stroke• increased high-density lipoprotein cholesterol and

triglycerides. • the effect on fibrinojen, platelet aggregation and

fibrinolysis. • congestive cardiomyopathy, cardiac arrhythmias, sudden

death.

Alcohol-2

• Moderate intake of alcohol is associated with lower risk of coronary heart disease when compared with non-drinkers.

• Some have suggested wine is the essential form,while others find that other alcoholic beverages such as beer and spirits are equally implicated.

Vitamins, minerals and food supplements

Preventive• Vitamin C• VitaminE• B-carotene• Copper• Iron• Selenium• Fish oil• Fibre

Causing• Homocysteine: A product of methionine metabolism and elevated blood levels of homocystein is associated with CHD

(Osgamian et al.1999)

Blood lipids

• LDL (Low density lipoprotein) is most atherogenic form

• Higher levels of HDL(High density lipoprotein) are associated with less disease

• The levels of serum triglycerides measured in the fasting state are associated with coronary heart disease

• Blood cholesterol can be lowered among adults with moderate changes in diet and loss of weight

Cigarette smoking

• Cigarette smoking addicts 20-80 per cent of adult men worldwide with somewhat lower proportion of adult women addicted.

• Cigarette smoking begins in youth and and gradually increases until it becomes nicotine addiction.

• In recent years, the focus has shifted to environmental tobacco smoke which affects non-smokers in public and private settings.

Cigarette smoking-2

• A chronic promoter of atherosclerotic lesions, this may be the result of injury to the arterial endothelium

• Acute risk factor for increasing sympathetic stimulation• Enhancing clotting• Pharmacological effects of nicotine and carbonmonoxide

are platelet adhesion, acute coronary constriction and tachycardia

• Linked to myocardial infarction, sudden death, stroke and peripheral vascular diseases

Overweight and Obesity• Obesity is associated with elevated blood pressure,

hyperlipidaemia, diabetes mellitus and insulin resistance.• Expert panels suggest a body mass index (BMI) above 25

is classified as overweight and above 30 as obese. (Eckel-Krauss 1998)

• One unit in BMI was associated with 12 per cent increase in the risk of hypertension. (Nurses Health Study 1998)

• Both insulin resistance and hyperglycaemia are significantly reduced when patients lose weight.

(Paisey et al. 1998)

Diabetes, Hyperglycaemia and Hyperinsulinaemia• Large vessel disease associated with DM in myocardial infarction,stroke,and periferial vascular disease.

• Microvascular disease is associated with retinopathy, renal disease and cardiomyopathy.

• Diabetes and hyperglycaemia are strongly related to atherosclerosis,obesity and abnormal lipit pattern.

Diabetes, Hyperglycaemia and Hyperinsulinaemia-2• The treatment of diabetes is based on control of blood glucose and treatment of associated risk factors.

• Lifestyle strategies, weight loss and physical activity can be effective at reducing blood glucose and controlling the associated risk factors (Type 2 diabetes)

• For Type 1 diabetes, insulin for glucose control and control of associated risk factors can reduce some diabetic complications.

Criteria for the Diagnosis of Diabetes

ADA.Classification and Diabetes Care.2013

Physical Inactivity

• Physical inactivity is associated with acute myocardial infarction and sudden death both for the initial event and recurrent events.

• Physical inactivity is associated with known risk factors including hypertension, hyperlipidaemia, diabetes mellitus and obesity.

Physical Inactivity-2

• Powel et al. calculated a relative risk of 1.9 compared with sedentary individuals in 1987.

• The Multiple Risk Factor Intervention Trial of over 12.000 men demonstrated similar relationship those with regular leisure time physical activity having lower risk of coronary hearth disease and death.

(Leon et al.1987)

Psychosocial factors

• Psychosocial factors including personality characteristics and the social environment are populary believed to play an important role in cardiovascular disease.

• Type A behavior is characterized by aggressiveness, competitive drive, preoccupation with deadlines, and time urgency.

Psychosocial factors-2• In the Western Collaborative Group Study, a prospective cohort of 3000 men was assessed by the structured interview.The relative risk of fatal and non-fatal coronary heart disease was approximately 2 for type A men.

• Recent research suggests that anger or hostility is an acute than chronic risk factor and associated with plaque rupture. (Muller et al. 1997)

Key Messages

• Improving the nutrition of the girls and women can prevent CVD in future generations.

• Implementation of policies to promote healthy lifestyles in children and youth is essential for prevention of CVD.

• Undernutrition of fetal life and infancy increases an individual’s vulnerability to CVD.

• Healthy behaviours are learned in childhood and continue in adulthood.

Key Messages

• Choices that people make regarding behaviour (tobacco use, use of alcohol, physical activity or diet) are shaped by the ‘’opportunities’’ that society offers to them.

• Poverty, lack of education and unplanned urbanization have a negative impact on cardiovascular health.

• Unfair distribution of power, money and resources increases exposure to cardiovascular risk factors.

References • Oxford Textbook of Public Health,Cardiovasculer and

Cerebrovasculer Diseases,Roger Detels, Robert Beaglehole, Mary Ann Lansang, Martin Gulliford, Oxford Univercity Press, 2009

• Hurst’s The Heart,A History of The Heart, The Burden Of İncreasing Worldwide Cardiovasculer Disease, Valentine Fusler, R.Mayne Alexander, Mc Graw-Hill Medical,2004

• Managing Cardiovasculer Risk, Socioeconomic aspacts of risk prediction, Owerweight, physical inactivity, insulin resistance, impaired glucose tolerance, diabetes, the metabolic syndrome and the cardiovascular risk, Ian M.Graham Ralph D’Agustino, Clinical Publishing Oxford, 2007

• Global Atlas on Cardiovascular disease prevention and control,Shanti Mentis, Pekka Puska, Bo Norrving,WHO in Collaboration with the World Heart Federation and the World Stroke Organization, 2011

References-2

• Maxcy-Rosenau-Last Public Health and Preventive Medicine, Heart Disease, Robert B.Wallace, Neal Kohatsu, 2007

• 66.World Health Assembly Foolow-up to the Political Decleration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases, May 2013

• Development of a limited set of action plan indicators to inform reporting on progress made in the implementation of the WHO Global Plan for the Prevention and Control of Noncommunicable Diseases 2013-2020, August 2013

• Global Strategy on Diet, Physical Activity and Health, WHO 2004

Web Sources

• Cardiovasculer diseases(CVDs) WHO• http://www.who.int./cardiovasculer_diseases/en/• ADA Standarts of Medical Care 2013 FİNAL 21 Dec.2012• http://care.diabetesjournals.org/content/36/supplement_1/S11.f

ull• Cholesterol Range Chart-Vaughn’s Summaries• http://www.vaughns-1-pagers.com/medicine/

cholesterolrangehtm.• Türkiye Hastalık Yükü Çalışması 2004, T.C.SAĞLIK

BAKANLIĞI, REFİK SAYDAM HIFZISSIHHAMERKEZİ BAŞKANLIĞI, HIFZISSIHHA MEKTEBİ MÜDÜRLÜĞÜ, Prof. Dr. Necdet ÜNÜVAR, Dr. Salih MOLLAHALİLOĞLU, Uzm. Dr. Nazan YARDIM

• http://ekutuphane.tusak.gov.tr/kitapalr/turkiye-hastalik-yuku-calismasi.pdf