International Comparisons in International Comparisons in CVD Morbidity and MortalityCVD Morbidity and Mortality

• CVD accounts for 25-45% of deaths CVD accounts for 25-45% of deaths among different countriesamong different countries

• CVD death rates (per 100,000) range CVD death rates (per 100,000) range from 1310 in Russia to 201 in Japan from 1310 in Russia to 201 in Japan (6.5 fold difference) in men and from (6.5 fold difference) in men and from 581 in Russia to 84 in France (7-fold 581 in Russia to 84 in France (7-fold difference)difference)

• USA ranks 16th for both men (413) and USA ranks 16th for both men (413) and women (201)women (201)

Secular Trends in CHD and Secular Trends in CHD and Stroke MortalityStroke Mortality

• From 1985-1992, greatest annual From 1985-1992, greatest annual decline (6-7%) in CHD seen in Israel decline (6-7%) in CHD seen in Israel among men and France among among men and France among women, USA intermediate (4%), women, USA intermediate (4%), increases in Poland and Romania.increases in Poland and Romania.

• Stroke death rates declined most in Stroke death rates declined most in Australia, Italy, and France (8-9%), Australia, Italy, and France (8-9%), USA about 3%.USA about 3%.

Age-Adjusted Death Rates for Coronary Heart Disease by Country and Sex, Ages 35-74, 1999

Age-Adjusted Death Rates for Stroke by Country and Sex, Ages 35-74, 1999

Change in Age-Adjusted Death Rates for Coronary Heart Disease by Country and Sex, Ages 35-74, 1990-1999

Men

Women

Change in Age-Adjusted Death Rates for Stroke by Country and Sex, Ages 35-74, 1990-1999

Men

Women

Migrant Studies Migrant Studies

• Ni-Hon-San Study showed Japanese Ni-Hon-San Study showed Japanese living in Japan to have the lowest living in Japan to have the lowest cholesterol levels and lowest rates of cholesterol levels and lowest rates of CHD, those living in Hawaii to have CHD, those living in Hawaii to have intermediate rates for both, and those intermediate rates for both, and those living in San Francisco to have the living in San Francisco to have the highest cholesterol levels and CHD highest cholesterol levels and CHD incidenceincidence

Approaches to Primary and Approaches to Primary and Secondary Prevention of CVDSecondary Prevention of CVD

• Primary prevention involves prevention of Primary prevention involves prevention of onset of disease in persons without symptoms.onset of disease in persons without symptoms.

• Primordial prevention involves the prevention Primordial prevention involves the prevention of risk factors causative o the disease, thereby of risk factors causative o the disease, thereby reducing the likelihood of development of the reducing the likelihood of development of the disease.disease.

• Secondary prevention refers to the prevention Secondary prevention refers to the prevention of death or recurrence of disease in those who of death or recurrence of disease in those who are already symptomaticare already symptomatic

Risk Factor Concepts in Risk Factor Concepts in Primary PreventionPrimary Prevention

• Nonmodifiable risk factors include age, Nonmodifiable risk factors include age, sexc, race, and family history of CVD, which sexc, race, and family history of CVD, which can identify high-risk populationscan identify high-risk populations

• Behavioral risk factors include sedentary Behavioral risk factors include sedentary lifestyle, unhealthful diet, heavy alcohol or lifestyle, unhealthful diet, heavy alcohol or cigarette consumption.cigarette consumption.

• Physiological risk factors include Physiological risk factors include hypertension, obesity, lipid problems, and hypertension, obesity, lipid problems, and diabetes, which may be a consequence of diabetes, which may be a consequence of behavioral risk factors.behavioral risk factors.

Population vs. High-Risk ApproachPopulation vs. High-Risk Approach• Risk factors, such as cholesterol or blood pressure, have a Risk factors, such as cholesterol or blood pressure, have a

wide bell-shaped distribution, often with a “tail” of high values.wide bell-shaped distribution, often with a “tail” of high values.• The “high-risk approach” involves identification and intensive The “high-risk approach” involves identification and intensive

treatment of those at the high end of the “tail”, often at treatment of those at the high end of the “tail”, often at greatest risk of CVD, reducing levels to “normal”.greatest risk of CVD, reducing levels to “normal”.

• But most cases of CVD do not occur among the highest levels But most cases of CVD do not occur among the highest levels of a given risk factor, and in fact, occur among those in the of a given risk factor, and in fact, occur among those in the “average” risk group.“average” risk group.

• Significant reduction in the population burden of CVD can Significant reduction in the population burden of CVD can occur only from a “population approachoccur only from a “population approach” shifting the entire ” shifting the entire population distribution to lower levels.population distribution to lower levels.

Pyramid of Risk Pyramid of Risk (Werner et al. (Werner et al. Canadian Journal of Canadian Journal of Cardiology Cardiology 1998; 14(Suppl) B:3B-10B)1998; 14(Suppl) B:3B-10B)

Expected Shifts in Cholesterol Distribution Expected Shifts in Cholesterol Distribution from High-Risk, Population, and from High-Risk, Population, and Combined ApproachesCombined Approaches

Population and Community-Wide Population and Community-Wide CVD Risk Reduction ApproachesCVD Risk Reduction Approaches

• Populations with high rates of CVD are those with Western Populations with high rates of CVD are those with Western lifestyles of high-fat diets, physical inactivity, and tobacco lifestyles of high-fat diets, physical inactivity, and tobacco use.use.

• Targets of a population-wide approach must be these Targets of a population-wide approach must be these behaviors causative of the physiologic risk factors or behaviors causative of the physiologic risk factors or directly causative of CVD.directly causative of CVD.

• Requires public health services such as surveillance Requires public health services such as surveillance (e.g.,BFRSS), education (AHA, NCEP), organizational (e.g.,BFRSS), education (AHA, NCEP), organizational partnerships (Singapore Declaration), and legislation/policy partnerships (Singapore Declaration), and legislation/policy (Anti-Tobacco policies)(Anti-Tobacco policies)

• Activities in a variety of community settings: schools, Activities in a variety of community settings: schools, worksites, churches, healthcare facilities, entire worksites, churches, healthcare facilities, entire communitiescommunities

A conceptual framework for public health A conceptual framework for public health practice in CVD prevention. practice in CVD prevention. (From Pearson et al., (From Pearson et al., J Public HealthJ Public Health. 2001; 29:69 –78) . 2001; 29:69 –78)

Communitywide CVD Communitywide CVD Prevention ProgramsPrevention Programs

• Stanford 3-Community Study (1972-75) showed Stanford 3-Community Study (1972-75) showed mass media vs. no intervention in high-risk mass media vs. no intervention in high-risk residents to result in 23% reduction in CHD risk residents to result in 23% reduction in CHD risk scorescore

• North Karelia (1972-) showed public education North Karelia (1972-) showed public education campaign to reduce smoking, fat consumption, campaign to reduce smoking, fat consumption, blood pressure, and cholesterolblood pressure, and cholesterol

• Stanford 5-City Project (1980-86) showed reductions Stanford 5-City Project (1980-86) showed reductions in smoking, cholesterol, BP, and CHD riskin smoking, cholesterol, BP, and CHD risk

• Minnesota Heart Health Program (1980-88) showed Minnesota Heart Health Program (1980-88) showed some increases in physical activity and in women some increases in physical activity and in women reductions in smokingreductions in smoking

Materials Developed for US Materials Developed for US Community Intervention TrialsCommunity Intervention Trials

• Mass media, brochures and direct mailMass media, brochures and direct mail• Events and contestsEvents and contests• ScreeningsScreenings• Group and direct educationGroup and direct education• School programs and worksite interventionsSchool programs and worksite interventions• Physician and medical setting programsPhysician and medical setting programs• Grocery store and restaurant projectsGrocery store and restaurant projects• Church interventionsChurch interventions• PoliciesPolicies

Individual and High-Risk ApproachesIndividual and High-Risk Approaches

• Primary Prevention Guidelines (1995) and Secondary Primary Prevention Guidelines (1995) and Secondary Prevention Guidelines (Revised 2001) released by the Prevention Guidelines (Revised 2001) released by the American Heart Association provide advice regarding American Heart Association provide advice regarding risk factor assessment, lifestyle modification, and risk factor assessment, lifestyle modification, and pharmacologic interventions for specific risk factorspharmacologic interventions for specific risk factors

• Barriers exist in the community and healthcare Barriers exist in the community and healthcare setting that prevent efficient risk reductionsetting that prevent efficient risk reduction

• Surveys of CVD prevention-related services show Surveys of CVD prevention-related services show disappointing results regarding cholesterol-lowering disappointing results regarding cholesterol-lowering therapy, smoking cessation, and other measures of therapy, smoking cessation, and other measures of risk reductionrisk reduction

PresentationPresentation• Examination:Examination:– Height: 6 ft 2 inHeight: 6 ft 2 in– Weight: 220 lb (BMI 28 kg/mWeight: 220 lb (BMI 28 kg/m22))– Waist circumference: 41 inWaist circumference: 41 in– BP: 150/88 mm HgBP: 150/88 mm Hg– P: 64 bpm P: 64 bpm – RR: 12 breaths/minRR: 12 breaths/min

• Cardiopulmonary exam:Cardiopulmonary exam: normal normal• Laboratory results:Laboratory results: – TC: 220 mg/dLTC: 220 mg/dL– HDL-C: 36 mg/dLHDL-C: 36 mg/dL– LDL-C: 140 mg/dLLDL-C: 140 mg/dL– TG: 220 mg/dLTG: 220 mg/dL– FBS: 120 mg/dLFBS: 120 mg/dL

Risk AssessmentRisk Assessment

Count major risk factorsCount major risk factors

• For patients with multiple (2+) risk For patients with multiple (2+) risk factorsfactors– Perform 10-year risk assessmentPerform 10-year risk assessment

• For patients with 0–1 risk factorFor patients with 0–1 risk factor– 10 year risk assessment not required10 year risk assessment not required– Most patients have 10-year risk <10%Most patients have 10-year risk <10%

ATP III Assessment of CHD RiskATP III Assessment of CHD Risk For persons For persons withoutwithout known CHD, other forms of known CHD, other forms of

atherosclerotic disease, or diabetes:atherosclerotic disease, or diabetes:• Count the number of risk factors:Count the number of risk factors:– Cigarette smokingCigarette smoking– Hypertension (BP Hypertension (BP 140/90 mmHg or on 140/90 mmHg or on

antihypertensive medication)antihypertensive medication)– Low HDL cholesterol (<40 mg/dL)Low HDL cholesterol (<40 mg/dL)†† – Family history of premature CHDFamily history of premature CHD

CHD in male first degree relative <55 yearsCHD in male first degree relative <55 years CHD in female first degree relative <65 yearsCHD in female first degree relative <65 years

– Age (men Age (men 45 years; women 45 years; women 55 years)55 years)• Use Framingham scoring for persons with Use Framingham scoring for persons with 2 risk 2 risk

factors* factors* (or with metabolic syndrome)(or with metabolic syndrome) to determine the to determine the absolute 10-year CHD risk. absolute 10-year CHD risk. (downloadable risk (downloadable risk algorithms at www.nhlbi.nih.gov)algorithms at www.nhlbi.nih.gov)

Assessing CHD Risk in MenAssessing CHD Risk in MenStep 1: Age

YearsPoints

20-34 -935-39 -440-44 045-49 350-54 655-59 860-64 1065-69 1170-74 1275-79 13

Step 2: Total Cholesterol

TC Points at Points at Points at Points atPoints at(mg/dL) Age 20-39 Age 40-49 Age 50-59 Age 60-69

Age 70-79 <160 0 0 0 0

0160-199 4 3 2 1

0200-239 7 5 3 1

0240-279 9 6 4 2

1280 11 8 5 3

1

HDL-C(mg/dL) Points

60 -1

50-59 0

40-49 1

<40 2

Step 3: HDL-Cholesterol

Systolic BP PointsPoints

(mm Hg) if Untreated if Treated

<120 0 0120-129 0 1130-139 1 2140-159 1 2160 2 3

Step 4: Systolic Blood Pressure

Step 5: Smoking Status

Points at Points at Points at Points atPoints at

Age 20-39 Age 40-49 Age 50-59 Age 60-69Age 70-79

Nonsmoker 0 0 0 00

Smoker 8 5 3 11

Age

Total cholesterol

HDL-cholesterol

Systolic blood pressure

Smoking status

Point total

Step 6: Adding Up the Points

Point Total 10-Year Risk Point Total 10-Year Risk

<0 <1% 118%

0 1% 1210%

1 1% 1312%

2 1% 1416%

3 1% 1520%

4 1% 1625%

5 2% 1730%

6 2%7 3%8 4%9 5%

10 6%

Step 7: CHD Risk

ATP III Framingham Risk Scoring

© 2001, Professional Postgraduate Services®

www.lipidhealth.org

Point Total 10-Year Risk Point Total 10-Year Risk

<9 <1% 2011%

9 1% 2114%

10 1% 2217%

11 1% 2322%

12 1% 2427%

13 2% 25 30%

14 2%15 3%16 4%17 5%18 6%19 8%

Assessing CHD Risk in WomenAssessing CHD Risk in WomenStep 1: Age

YearsPoints

20-34 -735-39 -340-44 045-49 350-54 655-59 860-64 1065-69 1270-74 1475-79 16

TC Points at Points at Points at Points atPoints at(mg/dL) Age 20-39 Age 40-49 Age 50-59 Age 60-69

Age 70-79 <160 0 0 0 0

0160-199 4 3 2 1

1200-239 8 6 4 2

1240-279 11 8 5 3

2280 13 10 7 4

2

HDL-C(mg/dL) Points

60 -1

50-59 0

40-49 1

<40 2

Step 3: HDL-Cholesterol

Systolic BP PointsPoints

(mm Hg) if Untreated if Treated

<120 0 0120-129 1 3130-139 2 4140-159 3 5160 4 6

Step 4: Systolic Blood Pressure

Step 5: Smoking Status

Points at Points at Points at Points atPoints at

Age 20-39 Age 40-49 Age 50-59 Age 60-69Age 70-79

Nonsmoker 0 0 0 00

Smoker 9 7 4 21

Age

Total cholesterol

HDL-cholesterol

Systolic blood pressure

Smoking status

Point total

Step 6: Adding Up the Points

Step 7: CHD Risk

Step 2: Total Cholesterol

ATP III Framingham Risk Scoring

Men

YearsPoints20-34 -935-39 -440-44045-49350-54655-59860-641065-691170-741275-7913

Step 1: AgeStep 1: Age

Expert Panel on Detection, Evaluation, and Treatment of High BloodCholesterol in Adults. JAMA. 2001;285:2486-2497.

Women

YearsPoints20-34 -735-39 -340-44 045-49 350-54 655-59 860-641065-691270-741475-7916

ATP III Framingham Risk Scoring

Step 2: Total CholesterolStep 2: Total CholesterolMen TC Points at Points at Points at Points at

Points at(mg/dL) Age 20-39 Age 40-49 Age 50-59 Age 60-69

Age 70-79 <160 0 0 0 0

0160-199 4 3 2 1

0200-239 7 5 3 1

0240-279 9 6 4 2

1280 11 8 5 3

1

WomenTC Points at Points at Points at Points at

Points at(mg/dL) Age 20-39 Age 40-49 Age 50-59 Age 60-69 Age

70-79 <160 0 0 0 0

0160-199 4 3 2 1

1200-239 8 6 4 2

1240-279 11 8 5 3

2280 13 10 7 4

2

ATP III Framingham Risk Scoring

Step 3: HDL-CholesterolStep 3: HDL-CholesterolMen

HDL-C(mg/dL)

Points60 -1

50-59 0

40-49 1

<40 2

Women

HDL-C(mg/dL)

Points60 -1

50-59 0

40-49 1

<40 2

ATP III Framingham Risk Scoring

Step 4: Systolic Blood PressureStep 4: Systolic Blood PressureMen

Systolic BP Points Points(mm Hg) if Untreated if Treated

<120 0 0120-129 0 1130-139 1 2140-159 1 2160 2 3

WomenSystolic BP Points

Points(mm Hg) if Untreated if

Treated <120 0 0

120-129 1 3130-139 2 4140-159 3 5160 4 6

ATP III Framingham Risk Scoring

Step 5: Smoking StatusStep 5: Smoking StatusMen

Points at Points at Points at Points atPoints at

Age 20-39 Age 40-49 Age 50-59 Age 60-69 Age 70-79 Nonsmoker 0 0 0 00

Smoker 8 5 3 11Women

Points at Points at Points at Points atPoints at

Age 20-39 Age 40-49 Age 50-59 Age 60-69 Age 70-79 Nonsmoker 0 0 0 00

Smoker 9 7 4 21

ATP III Framingham Risk Scoring

Step 6: Adding Up the PointsStep 6: Adding Up the Points(Sum From Steps 1–5)(Sum From Steps 1–5)

Expert Panel on Detection, Evaluation, and Treatment of High BloodCholesterol in Adults. JAMA. 2001;285:2486-2497.

AgeTotal cholesterol

HDL-cholesterol

Systolic blood pressure

Smoking status

Point total

ATP III Framingham Risk Scoring

Step 7: CHD Risk for MenStep 7: CHD Risk for MenPoint Total 10-Year Risk Point Total 10-

Year Risk<0 <1% 11

8%0 1% 12

10%1 1% 13

12%2 1% 14

16%3 1% 15

20%4 1% 16

25%5 2% 17

30%6 2%7 3%8 4%9 5%10 6%

ATP III Framingham Risk Scoring

What is WJC’s 10-year absolute What is WJC’s 10-year absolute risk of fatal/nonfatal MI?risk of fatal/nonfatal MI?• A 12% absolute risk is derived from points A 12% absolute risk is derived from points

assigned in Framingham Risk Scoring to:assigned in Framingham Risk Scoring to:– Age: Age: 66– TC: TC: 33– HDL-C: HDL-C: 22– SBP: SBP: 22– Total: 13 pointsTotal: 13 points

In 1992 he exercised 14 minutes in a Bruce protocol exercise stress test to 91% of his maximum predicted heart rate without any abnormal ECG changes. He started on a statin in 2001. But in Sept 2004, he needed urgent coronary bypass surgery.

Step 7: CHD Risk for WomenStep 7: CHD Risk for WomenPoint Total 10-Year Risk Point Total 10-

Year Risk<9 <1% 20

11%9 1% 21

14%10 1% 22

17%11 1% 23

22%12 1% 24

27%13 2% 25

30%14 2%15 3%16 4%17 5%18 6%19 8%

ATP III Framingham Risk Scoring

CHD Risk EquivalentsCHD Risk Equivalents

• Risk for major coronary events Risk for major coronary events equal to that in established CHDequal to that in established CHD

• 10-year risk for hard CHD >20%10-year risk for hard CHD >20%

Hard CHD = myocardial infarction + coronary death

Diabetes as a CHD Risk Diabetes as a CHD Risk EquivalentEquivalent

• 10-year risk for CHD 10-year risk for CHD 20% 20%• High mortality with established CHDHigh mortality with established CHD– High mortality with acute MIHigh mortality with acute MI– High mortality post acute MIHigh mortality post acute MI

CHD Risk EquivalentsCHD Risk Equivalents

• Other clinical forms of Other clinical forms of atherosclerotic disease (peripheral atherosclerotic disease (peripheral arterial disease, abdominal aortic arterial disease, abdominal aortic aneurysm, and symptomatic carotid aneurysm, and symptomatic carotid artery disease)artery disease)

• DiabetesDiabetes• Multiple risk factors that confer a Multiple risk factors that confer a

10-year risk for CHD >20%10-year risk for CHD >20%