Cardiovascular Health Banff 2012 CP1271671-5 Global Burden of - - PowerPoint PPT Presentation

The Global Burden of Cardiovascular Health

CP1271671-5

Banff 2012

Global Burden of Cardiovascular Disease – 2002

Developing (LIMC) countries

• 80% of worldwide CV deaths
• Occur at a younger age – impact
• n workforce and productivity
• 2010 – 70% of the elderly will live

in the developing world Total deaths – 57 million Cardiovascular 16.7 million HIV TB Malaria 5 million

Lopez: Lancet, 2006; Reddy: NEJM, 2004 WHO Global Status Report, 2011

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Yang: Lancet, 2008

20 40 60 80 100 1973 2005

Changing Distribution of the Causes of Death in P Rep of China

Proportion of deaths (%)

Year

Unknown Injury Other non-communicable diseases Chronic obstructive pulmonary disease Cerebro-cardiovascular disease Cancer Maternal and perinatal conditions Communicable diseases

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World Bank Report on China August 2011

“Reduction in mortality from CVD by only 1% between 2010- 2040 will save $10.7 trillion – 68% of China’s GDP in 2010 Lancet 2011

Changing demographics CV disease in India

• Aged <25 yr – 51%
• Aged 65 yr – 5%

6.2% (2020) 10.2% (2040)

Contrasting Burdens of Disease in India

Population undernourished Prevalence of obesity in affluent school children in Delhi

FAO report Sharma: Public Health Nutrition, 2007

• Age 4-17 yr
• Overweight – 22%
• Obese – 6%

1990-92 – 214.5 million 1999-01 – 213.7 million

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• Leading cause of death (approx

1/3 of total deaths)

• Expected to double in 10 yr
• 2015 – 50% of world’s CAD

deaths < age 50 yr among 1.4 billion South Asians globally

Enas: Indian Heart J, 2008

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Omran: Milbank Mem Fund Q, 1971 Olshansly: Millbank Mem Fund Q, 1986 Gaziano: Circ, 2003 Yusuf: Circ, 2005

Description Life expectancy Dominant form

• f CVD death

Stage 1 Pestilence and famine

• Malnutrition
• Infectious diseases

Infectious (RHD) Nutritional 35 yr Stage 2 Receding pandemics

• Improved nutrition

and public health

• Chronic disease
• Hypertension

50 yr Infectious (RHD) Stroke – hemorrhagic

Stages of Epidemiologic Transition

Proportion of death due to CVD (%)

<10 10-35

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Stages of Epidemiologic Transition

** Younger pt – lower socioeconomic status Elderly – higher socioeconomic status Omran: Milbank Mem Fund Q, 1971 Olshansly: Millbank Mem Fund Q, 1986 Gaziano: Circ, 2003 Yusuf: Circ, 2005 * Greater in high socioeconomic groups

Description Life expectancy Dominant form

• f CVD death

Stage 3 Degenerative and man-made diseases

•  fat and caloric intake
• Tobacco use
• Chronic disease deaths

> infections, malnutrition IHD* Stroke Hemorrhagic Ischemic >60 yr Stage 4 Delayed degenerative diseases

• Leading causes of

mortality CV and cancer deaths

• Prevention and Tx delays onset
• Age-adjusted CV death reduced
• IHD**
• Stroke
• CHF

>70 yr Ischemic Proportion of death due to CVD (%) 35-65 40-50

CVD event-free survival probability

Socioeconomic Status and Incident CV Events

CP1254525-2

• 22,688

subjects

• Women’s

Health Study

• Apparently

healthy female health professionals

Alberts: Circ, 2006

Education Income

CV Event-Free Survival

2 4 6 8 10 12 1.00 0.98 0.96 0.94 0.92

Follow-up (yr)

2 4 6 8 10 12

Follow-up (yr)

MS BS Doctorate/ MD 2-4 years nursing <2 years nursing $100,000

$50,000- 99,999

$40,000- 49,999 $30,000- 39,999 $20,000- 29,999 $19,000

Risk Factors Associated with MI in Africa

INTERHEART Study

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Steyn: Circ, 2005

Socioeconomic Status and OR for MI

0.0 0.2 0.4 0.6 0.8 1.0 1.2 1.4 1.6 1.8 2.0

Odds ratio

8 years 9-12 years Post secondary educ

0.0 0.5 1.0 1.5 2.0 2.5 3.0

Low income Intermediate income High income

Years of Formal Education

Income

Black Africans (Phase 3) Colored Africans Europeans/

• ther (Phase 4)

Black Africans (Phase 3) Colored Africans Europeans/

• ther (Phase 4)

89.2% Population attributable risk for MI

• Smoking history
• Diabetes history
• Hypertension history
• Abdominal obesity
• Apo B/Apo A-1 ratio

Odds ratio

Attained Education Level (AEL) and Impact

• n Risk Factors
• REACH registry
• 61,332 subjects
• Established CVD or

multiple risk factors

Increased among women; Goyal: Circ, 2010

Associations with AEL

* LIC       Risk factor Obesity Smoking Hypertension Diabetes Hypercholesterolemia Disease in 2 vascular beds HIC      

• 0-8 yr
• 9-12 yr
• Trade/technical
• University/college

Education levels

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*

5 10 15 20 25 30

5.3 Haynes: Am J Epidem, July 1984

10-Year Incidence of CHD (Men Aged 45-64 Years)

14.9 11.1 20.0

19

Spouse Behavior and CHD in Men

Framingham Study

%

23.1 11.5 24.0

n= 26 26 94 25 36 40 Wife's education 8 9 8 9-12 13 12 13 Husband's education 8 9-12

13

Years

Phase 5

(phase of increasing CV mortality)

?

• The negative impact
• f social upheaval

and health regression

• The age of inactivity

and obesity

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1962 1965 1970 1975 1980 1985 1990 1994 80 75 70 65 60 55

Declining Life Expectancy in Russia

Notzon: JAMA, 1998

Life Expectancy at Birth

Life expectancy (yr) Years

• U. S. females
• U. S. males

Russian females Russian males

CP1284274-2

Heart disease and stroke – 65% of decline in life expectancy Perestroika Anti-alcohol campaign Economic and social instability

•  alcohol
•  tobacco

• 8
• 6
• 4
• 2

2 1980-89 1989-2000 2000-2002

• 8
• 6
• 4
• 2

1980-89 1989-2000 2000-2002

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Time period EAPC (%)

Ford and Copewell: JACC, 2007

Phase 5 – the Age of Inactivity and Obesity

Mortality Rates from CHD – USA

?

Estimated Annual Percentage Change (EAPC) Males

*P<0.05 vs prior period

• 2.6
• 1.9*
• 3.7*
• 2.3*
• 6.2
• 0.5

EAPC (%)

Females

*P<0.05 vs prior period

• 4.8*
• 1.5
• 5.4
• 1.2*

1.5 Age 35-44 years Age 55 years

Time period

Risk Factors for CVD in the Developing World : Traditional and Novel ?

CP1271671-5

0.25 0.5 1 2 4 8 16

Odds ratio (99% CI)

Risk factor Sex

• Current

F smoking M

• Diabetes

F M

• HTN

F M

• Abdomial

F

• besity

M Female Male

Risk of AMI After Adjustment for Age, Sex, and Geographic Region

Yusuf: Lancet, 2004

• Psycho-

F social index M

• Fruits/veg

F M

• Exercise

F M

• Alcohol

F M

• ApoB/ApoA1

F ratio M

CP1274880-8

All 9 risk factors account for 90.4% of population attributable risk (PAR)

• Diet/lack of exercise
• Tobacco incl second-hand smoke
• Aging society
• HIV survivors
• Air pollution
• Rural  urban migration

Psychosocial/economic stressors

• Culture

The Potential Epidemic of CVD in Developing Countries

• Limited national

resources

• Lack of infrastructure

Pre- disposing factors “The perfect storm”

• Salt sensitivity
• Insulin resistance
• Lipid/fat

metabolism

• Low birth weights

Genetic/phenotypic vulnerability? – thrifty gene concept?

Hostile CV environment Obesity Traditional healers

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“The human race has had long experience and a fine tradition in surviving adversity;

Alan Gregg 1890-1957 Rockefeller Foundation

but we now face a task for which we have little experience, the task

• f surviving prosperity”

CP1344939-4

CAD in the UK and USA – 1920’s

Recent MI (UK prior to WWI) 1-2 necrosies/year with recent coronary thrombosis/AMI The London Hospital

Morris: Lancet, 1951

CHD (USA) “The disease in my youth was hardly a problem…but I know that my professors did have occasional cases among their well-to-do patients whom they cared for at home

White PD: Am J Pub Health, 1957

Angina pectoris “It is a rare disease…a case a year is about average, even in the large metropolitan hospitals.”

Osler: Principles and Practice of Medicine, 1912

“Seven-fold increase from 1907-44 to 1944-49 in the number of cases

• f coronary heart

disease.”

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Spectrum of Heart Disease in Urban Blacks in S Africa – 2006

The Heart of Soweto Study

• 1.1 million est.
• 85% black

59% women Mean age 52-8 yr CV risk factors – 87%

Sliwa: Lancet, 2008

1,593 New Cases of Cardiovascular Disease

Other diagnoses 9% Valvular heart disease (17%) (58% – rheumatic)

CP1305101-2

CAD 10% (6% – blacks 38% – other) Heart failure 44% Hypertension 19%

Proportion of Reduction in Deaths Due to CHD Attributable to Treatments and Changes in Risk Factors

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Bandosz: BMJ, 2012 20 40 60 80 100

New Zealand, 1974-81 IMPACT New Zealand, 1982-93 Holland, 1978-85 IMPACT Scotland, 1975-94 IMPACT England and Wales, 1981-2000 IMPACT Sweden, 1986-2002 Finland, 1972-92 IMPACT Finland, 1982-97 IMPACT Iceland, 1981-2006 U.S., 1968-76 U.S., 1980-90 IMPACT U.S., 1980-2000 IMPACT Poland, 1991-2005

%

Treatments Risk factors Unexplained

CP1234288-1

“Nobody in football should be called a genius. A genius is a guy like Norman Einstein.”

Joe Theisman

The Positive Model of the Hunter-Gatherer Life Style

Baseline 7 weeks as hunter-gatherers

• 10 Aborigines
• Derby, W. Australia
• Diabetics

O’Dea: Diabetes 1984 Brown: 2011

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4.5 4.7 4.9 5.1 5.3 5.5 5.7 5.9 6.1 105 110 115 120 125 80 100 120 140 160 7 9 11 13 15 17 19 21

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Trends in Age-Adjusted Mortality in Cuba

1985-2000

Franco: Am J Epidemiol, 2007

Diabetes mortality (per 100,000)

Type 2 Diabetes

1980 1985 1990 1995 2000 2005

Year CHD mortality (per 100,000)

Coronary Heart Disease

Cancer mortality (per 100,000)

Cancer

All-cause mortatlity (per 100,000)

All Causes

1980 1985 1990 1995 2000 2005

Year

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Early Consequences of the Framingham Study

Identification of HTN, hypercholesterolemia and smoking as risk factors 1961 – 6-year follow-up report "The Framingham Study provided the NIH and the country with a huge return on it's investment" NIH AHA National programs 1964 – Surgeon General’s report re smoking

• Diet/salt

reduction

• Smoking cessation
• Saturated and transfat reduction
•  Physical activity

Tackling the Roots

• f CV Risk Factors

Voluntary Mandatory – National Individual Industry

Strategies for Prevention of CVD

Population based Individual intervention in high-risk population

Improved physical environments Healthy public policies Food labeling Cultural & public awareness Legislation Corporate actions

Lipid lowering BP control Platelet inhibitors Role of polypill ?**

Effective

**TIPS – The Indian Polycap Study Lancet, 2009

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United Nations Millenium Development Goals: 2000-2015

CP1278210-3

International/national self-interests Moral and ethical

• bligation

“Why rich countries should care about the world’s least healthy people.”

L.O. Gostin: JAMA, 2007

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Health, economy, trade, stability