CVD Definitions and Statistics Jan 2012

Cardiovascular Epidemiology and Prevention
Nathan D. Wong, PhD, FACC, FAHA

Professor and Director, Heart Disease Prevention Program, Division of Cardiology, University of California, Irvine President, American Society of Preventive Cardiology
Textbooks
Cardiovascular Epidemiology: Definitions, Concepts, Historical Perspectives and Statistics
Definitions
CORONARY ARTERY DISEASE (CAD) or CORONARY HEART DISEASE (CHD) (often broadly referred to as ISCHEMIC HEART DISEASE (IHD): primarily myocardial infarction and sudden coronary death, broader definition may include angina pectoris, atherosclerosis, positive angiogram, and revascularization (perceutaneous coronary interventions, or PCI such as angioplasty and stents)
CARDIOVASCULAR DISEASE or CVD includes CHD, cerebrovascular disease, peripheral vascular disease, and other cardiac conditions (congenital, arrhythmias, and congestive heart failure)
Definitions (cont.)
SURROGATE MEASURES include: carotid intimal medial thickness (IMT), coronary calcium, angiographic stenosis, brachial ultrasound flow mediated dilatation (FMD) Hard endpoints include myocardial infarction, CHD death, and stroke
CVD and other major causes of death for all males and females (United States: 2007).
450,000 421,918 400,000 391,886
350,000 292,857 270,018
300,000
Deaths
250,000
200,000
150,000 79,827 100,000 66,689 61,235 35,478 21,800 0 A B C D E F A B D F C E 52,832 43,879 35,904
50,000
Males
Females
Source: NCHS and NHLBI. A indicates CVD plus congenital CVD; B, cancer; C, accidents; D, CLRD; E, diabetes; and F, Alzheimer's disease.
2010 American Heart Association, Inc. All rights reserved. Roger VL et al. Published online in Circulation Dec. 15, 2010
Trends in cardiovascular procedures, United States: 19792009

1400
1200
Procedures in Thousands
1000
800
600
400
200
0 1979 1980 1985 1990 Years 1995 2000 2005 2009
Catheterizations
Bypass
PCI
Carotid Endarterectomy
Pacemakers
Note: Inpatient procedures only. Source: National Hospital Discharge Survey, NCHS, and NHLBI.
Direct and indirect costs (in billions of dollars) of major cardiovascular diseases and stroke (United States: 2008)
200 190.3
180
160
140
Billions of Dollars
120
100
80
60
50.6 34.3 22.5
40
20
Heart disease
Source: National Heart, Lung, and Blood Institute.
2011 American Heart Association, Inc. All rights reserved.
Hypertension
Stroke
Other CVD
Roger VL et al. Published online in Circulation Dec. 15, 2011
Projected Total Costs of CVD, 20152030 (in Billions 2008$) in the United States
1200
1117.6
1000
886.2
Total Dollars (in Billions)
800
704.7
564.9
600
408.5
400
245.2 194.1
223.8 186.7 250.5 97.0 74.1 44.6 57.0 69.1 143.0 111.2 87.1 197.8
320.0
200
153.2 121.1 132.4
156.9
0 All CVD Hypertension CHD HF Stroke Other CVDs
2015
2020
2025
2030
Unpublished data tabulated by AHA using methods described in Circulation. 2011;123:933944.

550
Deaths in Thousands
500 450 400 350 79 80 85 90 Years Males Females 95 00 06
Discharges in Millions
6 5 4 3 2 1 0 70 75 80 85 Years 90 95 00 06
Hospital discharges for cardiovascular diseases. (United States: 1970-2006). Note: Hospital discharges include
people discharged alive, dead and status unknown. Source: NCHS and NHLBI.
Prevalence of CVD in adults 20 years of age by age and sex (NHANES: 20052008)
100
90 80.1 80 72.6 70 Percent of Population 60 50 40 30 20 10 0 20-39 40-59 60-79 80+ 39.3 37.2 71.9 86.7
14.2 9.7
Men
Women
Source: NCHS and NHLBI. These data include CHD, HF, stroke, and hypertension.
Deaths due to diseases of the heart (United States: 19002008)

1,000
Deaths in Thousands
800
600
400
200
Years
0 1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2008
Source: National Center for Health Statistics.

1,000
Deaths in Thousands
831
800 600 400 200

25 21 48 50 120 138 81 101 315 242 165 85 560
0 <45 45-54 55-64 65-74 Ages CVD Cancer 75-84 85+ Total
CVD deaths vs. cancer deaths by age. (United States: 2006). Source: NCHS.
CVD and other major causes of death for all males and females (United States: 2008)
450,000 419,730 400,000 392,210
350,000 295,259 270,210 Deaths 250,000
300,000
200,000
150,000 78,378 100,000 67,122 35,346 24,516 73,968 57,919 43,524 35,207
50,000
0 A B C D E F A B D F C E
Males
Females
Source: NCHS and NHLBI. A indicates CVD plus congenital CVD; B, cancer; C, accidents; D, CLRD; E, diabetes; and F, Alzheimer's disease.
Prevalence of stroke by age and sex (NHANES: 20052008)

18 16
14.5 14.8
14 12 10
8.2
Percent of Population
8 6 4
2.4
7.2
2
0.3
0.5
1.6
0 20-39 40-59
Age
60-79
80+
Men
Source: NCHS and NHLBI.
Women
Prevalence of stroke by age and sex (NHANES: 20052008).

18 16
14.5
14.8
14
12 10
8.2
8 6 4
2.4
7.2
2
0.3 0.5
1.6
0 20-39 40-59
Age
60-79
80+
Men
Women

Coronary Heart Disease Stroke 14 7 7 17 4 HF* 51 High Blood Pressure Diseases of the Arteries Other
Percentage breakdown of deaths from cardiovascular diseases (United States: 2006) * - Not a true underlying cause.
Source: NCHS.
16 14 12 10 8 6 4 2 0
13.8 12.2 9.3 4.8 2.2 0.1 0.2 20-39 1.2 60-79 Women 80+
40-59 Men
Prevalence of heart failure by age and sex (NHANES: 2005-2006). Source: NCHS and NHLBI.
700
Discharges in Thousands
600 500 400 300 200 100 0 79 80 85 90 Years Male Female 95 00 06
Hospital discharges for heart failure by sex. (United States: 1979-2006). Source: NHDS/NCHS and NHLBI.
Note: Hospital discharges include people discharged alive, dead and status unknown.
Development of Atherosclerotic Plaques

Fatty streak Normal Lipid-rich plaque
Foam cells Fibrous cap
Thrombus
Lipid core
Ross R. Nature. 1993;362:801-809.
PDAY: Percentage of Right Coronary Artery Intimal Surface Affected With Early Atherosclerosis
30 20 10 0 30 20 10 0
Men
Raised lesions 30 Fatty streaks 20 10 0
Women
Intimal surface (%)
15-19 20-24 25-29 30-34 White
30 20 10
15-19 20-24 25-29 30-34 White
15-19 20-24 25-29 30-34 Black
15-1920-2425-2930-34 Black
Age (y)
PDAY= Pathobiological Determinants of Atherosclerosis in Youth. Strong JP, et al. JAMA. 1999;281:727-735.
Most Myocardial Infarctions Are Caused by Low-Grade Stenoses
Falk E et al, Circulation, 1995.
Pooled data from 4 studies: Ambrose et al, 1988; Little et al, 1988; Nobuyoshi et al, 1991; and Giroud et al, 1992. (Adapted from Falk et al.)
Coronary Remodeling
Progression
Compensatory expansion maintains constant lumen Expansion overcome: lumen narrows
Normal vessel
(Adapted from Glagov et al.) Glagov et al, N Engl J Med, 1987.
Minimal CAD
Moderate CAD
Severe CAD
Atherosclerotic Plaque Rupture and Thrombus Formation

Growth of thrombus
Intraluminal thrombus
Blood Flow
Intraplaque thrombus Adapted from Weissberg PL. Eur Heart J Supplements 1999:1:T1318
Lipid pool
Features of a Ruptured Atherosclerotic Plaque

Eccentric, lipid-rich
Fragile fibrous cap Prior luminal obstruction < 50% Visible rupture and thrombus
Constantinides P. Am J Cardiol. 1990;66:37G-40G.
Vulnerable Versus Stable Atherosclerotic Plaques

Vulnerable Plaque
Lumen
Fibrous Cap
Lipid Core
Thin fibrous cap Inflammatory cell infiltrates: proteolytic activity Lipid-rich plaque
Stable Plaque Lumen

Fibrous Cap Lipid Core
Thick fibrous cap Smooth muscle cells: more extracellular matrix Lipid-poor plaque
Libby P. Circulation. 1995;91:2844-2850.
Correlation of CT angiography of the coronary arteries with intravascular ultrasound illustrates the ability of MDCT to demonstrate calcified and non-calcified coronary plaques (Becker et al., Eur J Radiol 2000)
Non-calcified, soft, lipid-rich plaque in left anterior descending artery (arrow) (Somatom Sensation 4, 120 ml Imeron 400). The plaque was confirmed by intravascular ultrasound (Kopp et al., Radiology 2004)
Concept of cardiovascular risk factors
Age, sex, hypertension, hyperlipidemia, smoking, diabetes, (family history), (obesity)
Kannel et al, Ann Intern Med 1961
Major Risk Factors

Cigarette smoking (passive smoking?) Elevated total or LDL-cholesterol Hypertension (BP 140/90 mmHg or on antihypertensive medication) Low HDL cholesterol (<40 mg/dL) Family history of premature CHD CHD in male first degree relative <55 years CHD in female first degree relative <65 years Age (men 45 years; women 55 years)
HDL cholesterol 60 mg/dL counts as a negative risk factor; its presence removes one risk factor from the total count.
Other Recognized Risk Factors

Obesity: Body Mass Index (BMI) Weight (kg)/height (m2) Weight (lb)/height (in2) x 703 Obesity BMI >30 kg/m2 with overweight defined as 25-<30 kg/m 2 Abdominal obesity involves waist circumference >40 in. in men, >35 in. in women Physical inactivity: most experts recommend at least 30 minutes moderate activity at least 4-5 days/week
Prevalence (unadjusted) estimates for poor, intermediate and ideal cardiovascular health for each of the 7 metrics of cardiovascular health in the AHA 2020 goals, US children aged 12-19 years, NHANES 2007-2008
Age-standardized prevalence for poor, intermediate and ideal cardiovascular health for each of the 7 metrics of cardiovascular health in the AHA 2020 goals, among US adults >20 years of age, NHANES 2007-2008
____________________________________________________________
Lifetime Risk of Coronary Heart Disease in the Framingham Study

______________________________________________________________
Men
Women
At age 40 years: 48.6% At age 70 years: 34.9%

Lloyd-Jones et al. Lancet 1999; 353:89-92
31.7% 24.2%
_________________________________________________________________
____________________________________________________________
First Coronary Events: Framingham Study

________________________________________________________
Percent as Specified Event

Myocardial Infarction Age Men Women
35-64 43% 28% 65-84 55% 44%
Angina Pectoris Men Women

41% 28% 59% 41%
Sudden Death Men Women

9% 4% 11% 7.4%
____________________________________________________________
Framingham Study 44 year follow-up.
Estimated 10-Year CHD Risk in 55-Year-Old Adults According to Levels of Various Risk Factors
Framingham Heart Study
40 35 30 25 20 15 10 5 0
Estimated 10-Year Rate (%)
37 25 20 13 5 5 8 27 Men Women
A
Blood Pressure (mm Hg) Total Cholesterol (mg/dL) HDL Cholesterol (mg/dL) Diabetes Cigarettes
mm Hg = millimeters of mercury mg/dL = milligrams per deciliter of blood
B
140/90 240 50 No No
C
140/90 240 40 Yes No
D
140/90 240 40 Yes Yes
120/80 200 50 No No
Source: Circulation 1998;97:1837-1847.
Estimated 10-Year Stroke Risk in 55Year-Old Adults According to Levels of Various Risk Factors
Framingham Heart Study
Estimated 10-Year Rate (%)
30 25 20 14.8 15 10 5 0 2.6 4 1.1 5.4 2 3.5 8.4 6.3 19.1 22.4 27
C
Men
D
Women
Systolic BP* Diabetes Cigarettes Prior Atrial Fib. Prior CVD
A 95-105 No No No No
B 130-148 No No No No
C 130-148 Yes No No No
D 130-148 Yes Yes No No
E 130-148 Yes Yes Yes No
F 130-148 Yes Yes Yes Yes
Source: Stroke 1991;22:312-318.
*BP in millimeters of mercury (mmHg)
Offspring CVD Risk by Parental CVD Status: Framingham Study

Risk Ratio
2.5 2.5
2 2
2.2
Parental CVD <55 men, <65 Women NONE MATERNAL PATERNAL
1.5 1 1
1.0
1.7
1.7
1.7
1.0
0.5 0.5 0 0
Men MEN
Women WOMEN
Adjusted for: age, total/HDL Chol. ratio, SBP, smoking, diabetes, BMI
Risk imposed by a strong family history of heart attacks varies widely depending on the burden of modifiable risk factors
Multivariable Risk
9
Doubts about cholesterol as late as 1989
_______________________________________________________________________________
Lifetime Risk of CHD Increases with Serum Cholesterol

___________________________________________________________________________
60 50 40
44 57
Cholesterol <200 mg 200-239 mg
>240 mg
Percent
30 20 10 0
34 29 19 33
Men
Women
Framingham Study: Subjects age 40 years

DM Lloyd-Jones et al Arch Intern Med 2003; 1966-1972
Correlation Between Serum Cholesterol and CVD Mortality

30 6-Year CVD Death Rate Per 1000 25 20 15 45-49 years 10 5 0 40-44 years 35-39 years
Multiple Risk Factor Intervention Trial (MRFIT) N=325,346
Untreated Patients 55-57 years 50-54 years
Q1 (<182)
Q2 (182-202)
Q3 (203-220)
Q4 (221-244)
Q5 (>244)
Serum Cholesterol Quintile (mg/dL)

Q = serum cholesterol quintile.
Kannel WB et al. Am Heart J. 1986;112:825-836.
Trends in mean total serum cholesterol among adolescents 1217 years of age by race, sex, and survey year (NHANES: 19881994*, 19992004 and 2005-2008).
180
175
174
Mean Total Blood Cholesterol
170 165 165 163 161 160 159 157 155 155 154 166 163 161 163 162 160 158
158
150
145
140 NH White Males NH Black Males NH White Females NH Black Females Mex. Am. Males Mex. Am. Females
1988-94
1999-2004
2005-2008
Source: NCHS and NHLBI. NH indicates non-Hispanic. Mex. Am. indicates Mexican American. * Data for Mexican Americans not available.
Trends in mean total serum cholesterol among adults ages 20 by race and survey year, (NHANES: 19881994, 19992004 and 20052008).
210 206 205 205 203 204 201 200 198 198 201
Mean Serum Total Cholesterol
195 192 190
185
180 NH White NH Black Mexican American
1988-94
Source: NCHS and NHLBI. NH indicates non-Hispanic.
1999-2004
2005-2008
________________________________________________________
___________________________________________________________
CK Friedberg on Hypertension: Diseases of the Heart 1996
There is a lack of correlation in
most cases between the severity and duration of hypertension and development of cardiac complications. _______________________________________________________________
Relation of Non-Hypertensive Blood Pressure to Cardiovascular Disease

Vasan R, et al. N Engl J Med 2001; 345:1291-1297
10-year Age- Adjusted Cumulative Incidence

12% 10% 8%
7.6
<120/80 mm Hg 120-129/80-84 mm Hg 130-139/85-89 mm Hg
Hazard Ratio* SBP

10.1
Women Men 1.0 1.5 2.5 1.0 1.3 1.6
<120/80 120-129 130-139
6% 4% 2% 0% Women
2.8 1.9 4.4
5.8
H.R. adjusted for age, BMI, Cholesterol, Diabetes and smoking *P<.001
Men
Framingham Study: Subjects Ages 35-90 yrs.
Prevalence of High Blood Pressure in adults 20 years of age by age and sex (NHANES: 20052008)
90 80 70 64.0 Percent of Population 60 50 40 30 20 11.1 10 0 20-34 35-44 45-54 Age 55-64 65-74 75+ 6.8 37.1 54.0 69.3 66.7 78.5
53.3
35.2
25.1 19.0
Male
Female
Source: NCHS and NHLBI. Hypertension is defined as SBP 140 mm Hg or DBP 90 mmHg, taking antihypertensive medication, or being told twice by a physician or other professional that one has hypertension.
90 80 70 60 50 40 30 20 10 0
Percent of Population With Hypertension
78.8 79.0
82.3 67.6 74.7 69.1 70.1 52.1
46.5 45.4 46.1 35.2
Awareness Total Population NH Whites
Treatment NH Blacks
Controlled Mexican Americans
Extent of awareness, treatment and control of high blood pressure by race/ethnicity (NHANES : 2005-2006).
_______________________________________________________________
CK Friedberg on Hypertension _______________________________________________________________ Diseases of the Heart 1966 Hypertension imposes a load on the heart which for many years may be compensated by left ventricular hypertrophy
_______________________________________________________________
CVD Risk Imposed by ECG-LVH Framingham Study 36-yr. Follow-up

_______________________________________________________________
Age-adjusted Rate per 1000 Age Men Women 35-64 164 135 65-94 234 235
Risk Excess Risk Ratio per 1000 Men Women Men Women 4.7*** 7.4*** 129 117 2.8*** 4.1*** 51 178
_____________________________________________________________
Biennial Rate per 1000. CVD=CHD, stroke, peripheral vascular disease, heart failure ***P<0.001
____________________________________________________________
Smoking Statement Issued in 1956 by American Heart Association

It is the belief of the committee that much greater knowledge is needed before any conclusions can be drawn concerning relationships between smoking and death rates from coronary heart disease. The acquisition of such knowledge may well require the use of techniques and research methods that have not hitherto been applied to this ___________________________________________________________ problem.
___________________________________________________________
CHD Risk by Cigarette Smoking. Filter Vs. Non-filter. Framingham Study. Men
<55 Yrs.
14-yr. Rate/1000
250 200
206 210
Non-Smoker Reg. Cig. Smoker Filter Cig. Smoker
150 100 50 0 Total CHD Myocardial Infarction

119
112 210
59
Prevalence of students in grades 9 to 12 reporting current cigarette use by sex and race/ethnicity (YRBSS, 2009)
25 22.3 22.8
20 Percent of the Population
19.4 16.7
15
10.7 10 8.4
0 NH White NH Black Hispanic
Males
Females
Source: MMWR Surveill Summ. 2010;59:1142.NH indicates non-Hispanic.

Prevalence of current smoking for adults > 18 years of age by race/ethnicity and sex (NHIS: 2007-2009)
30
26.8 25 22.9 23.6
20 17.9
19.9 18.9 17.0

15.4
15
10
9.3
5.4
0 Men Women
NH White
NH Black
Hispanic
Asian*
American Indian/Alaska Native*
All percentages are age-adjusted. NH indicates non-Hispanic. *Includes both Hispanics and non-Hispanics. Data derived from Centers for Disease Control and Prevention/National Center for Health Statistics, Health Data Interactive.
Prevalence of current smoking for adults > 18 years of age by race/ethnicity and sex (NHIS: 2006-2008)
35 30.2 30
25 Percent of Population
24.0
25.0 22.1 21.0
20
18.4 17.1 15.7
15
10
9.4
4.5
0 Men Women
NH White
NH Black
Hispanic
Asian*
American Indian/Alaska Native*
Source: CDC/NCHS, Health Data Interactive. All percentages are age-adjusted. NH indicates non-Hispanic. * Includes both Hispanics and non-Hispanics.
Diseases of The Heart Charles K Friedberg MD, WB ________________________________________________________________ Saunders Co. Philadelphia, 1949
The proper control of diabetes is obviously desirable even though there is uncertainty as to whether coronary atherosclerosis is more frequent or severe in the uncontrolled diabetic ______________________________________________________________
Risk of Cardiovascular Events in Diabetics

Framingham Study
_________________________________________________________________
Cardiovascular Event Coronary Disease Stroke Peripheral Artery Dis. Cardiac Failure All CVD Events
Age-adjusted Biennial Rate Age-adjusted Per 1000 Risk Ratio Men Women Men Women 39 21 1.5** 2.2*** 15 6 2.9*** 2.6*** 18 18 3.4*** 6.4*** 23 21 4.4*** 7.8*** 76 65 2.2*** 3.7***
_________________________________________________________________ Subjects 35-64 36-year Follow-up **P<.001,***P<.0001
Age-adjusted prevalence of physician-diagnosed diabetes in adults 20 years of age by race/ethnicity and sex (NHANES: 20052008).
16 14.3 14 12.7 12 11.0 Percent of Population 10 14.7
8 6.8 6 6.5
Male
Female
NH White
Source: NCHS and NHLBI. NH indicates non-Hispanic.
NH Black
Mexican American
Trends in diabetes prevalence in adults 20 years of age, by sex (NHANES: 19881994 and 20052008).
9
8.2 8 7 Percent of Population 7.9
6
5
5.4
5.4
4.1 4 3.4 2.5
3
2 1
2.3
0
Physician Diagnosed 1988-94 Undiagnosed 1988-94 Physician Diagnosed 2005-08 Undiagnosed 2005-08
Male
Female
Source: NCHS, NHLBI.

Skepticism About Importance of Obesity

Keys A, Aravanis C, Blackburn H, et al. Ann Intern Med 1972; 77:15-27. Concluded that all the excess risk of coronary heart disease in the obese derives from its atherogenic accompaniments, illogically leaving the impression that obesity is therefore unimportant. Mann GV. N Engl J Med 1974; 291:226-232. The contribution of obesity to CHD is either small or non-existent. It cannot be expected that treating obesity is either logical or a promising approach to the management of CHD. Barrett-Connor EL. Ann Intern Med 1985; 103:1010-1019 NIH consensus panel is equivocal about the role of obesity as a cause of CHD.
Relation of Weight Change to Changes in

Atherogenic Traits: The Framingham Study
Frantz Ashley, Jr. and William B Kannel
J Chronic Dis 1974
Weight gain is accompanied by atherogenic alterations in blood lipids, blood pressure, uric acid and carbohydrate tolerance. It seems reasonable to expect that correction of overweight will improve the coronary risk problem. Avoidance of overweight would seem a desirable goal in the general population if the appalling annual toll from disease is to be substantially reduced.
Trends in the prevalence of obesity among US children and adolescents by age and survey year (National Health and Nutrition Examination Survey: 1971-1974, 1976-1980, 1988-1994, 19992002 and 20052008)
20
18
16 14 12 10 8 6.5 6 4.0 4 2 0 11.3 15.9
17.4 16.0
17.9
10.5
6.1
5.0
6-11
Age (Years)
12-19
1971-1974
1976-1980
1988-1994
1999-2002
2005-2008
Data derived from Health, United States, 2010: With Special Feature on Death and Dying. NCHS, 2011.
Age-adjusted prevalence of obesity in adults 2074 years of age, by sex and survey year (NHES: 196062; NHANES: 197174, 197680, 198894, 1999-2002 and 2005-08)
40 36.2 35 33.3 34.0
30 Percent of Population
28.1
26.0
25
20.6
20
16.8
15.7 17.1
15
12.2 10.7
12.8
10
0 Men Women
1960-62
1971-74
1976-80
1988-94
1999-2002
2005-08
Data derived from Health, United States, 2010: With Special Feature on Death and Dying. NCHS, 2011.
Risk Factor Sum and Obesity

Framingham Study
3 2.4 1.8 1.2 0.6 0 Q1 Thin Q2 Q3 Q4 Q5 Obese Overall (1971) (1971-74) and (1989-93) (1989)
Risk Factor Sum
Risk factors accumulate with weight gain
Risk variables include bottom quintile for HDL-C and top quintiles for cholesterol, SBP, triglycerides and glucose
Wilson PWF, & Kannel WB Nutr Clin Care 1999; 1:44-50
Prevalence of students in grades 912 who met currently recommended levels of PA during the past 7 days by race/ethnicity and sex (YRBS: 2009).
50 47.3 45 40 35 43.3 41.3
31.3 30 25 20 15 24.9 21.9
10
5 0 Male Female
NH White
NH Black
Hispanic
Currently recommended levels is defined as activity that increased their heart rate and made them breathe hard some of the time for a total of at least 60 minutes per day on 5 of the 7 days preceding the survey. Source: MMWR Surveillance Summaries.1 NH indicates non-Hispanic.
Prevalence of regular leisure-time physical activity among adults > 18 years of age by race/ethnicity and sex (NHIS: 2009).
45 40.1
40 36.0 35 29.7 25.9 25 24.1 36.2
30
20
15
10
0 Men Women
NH White
NH Black
Hispanic
Source: Pleis et al, 2010. NH indicates non-Hispanic. Percents are age-adjusted. Regular leisure-time physical activity is defined as 3 or more sessions per week of vigorous activity lasting at least 20 minutes or five or more sessions per week of light/moderate activity lasting at least 30 minutes.
Prevalence of students in grades 9 to 12 reporting current cigarette use by sex and race/ethnicity (YRBSS, 2009).
25 22.3 22.8
20
19.4 16.7
Percent of the Population
15
10.7 10 8.4
0 NH White NH Black Hispanic
Males
Females
Source: MMWR Surveill Summ. 2010;59:1142.NH indicates non-Hispanic.

Risk Assessment
Count major risk factors For patients with multiple (2+) risk factors
Perform 10-year risk assessment
For patients with 01 risk factor

10 year risk assessment not required Most patients have 10-year risk <10%
ATP III Assessment of CHD Risk

For persons without known CHD, other forms of atherosclerotic disease, or diabetes: Count the number of risk factors:
Cigarette smoking Hypertension (BP 140/90 mmHg or on antihypertensive medication) Low HDL cholesterol (<40 mg/dL) Family history of premature CHD

Age (men 45 years; women 55 years)
CHD in male first degree relative <55 years CHD in female first degree relative <65 years
Use Framingham scoring for persons with 2 risk factors* (or with metabolic syndrome) to determine the absolute 10-year CHD risk. (downloadable risk algorithms at www.nhlbi.nih.gov) Expert Panel on Detection, Evaluation, and Treatment of
High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.
2001, Professional Postgraduate Services www.lipidhealth.org
ATP III Framingham Risk Scoring
Assessing CHD Risk in Men

Step 1: Age Years 20-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 Points -9 -4 0 3 6 8 10 11 12 13 Step 4: Systolic Blood Pressure Systolic BP (mm Hg) <120 120-129 130-139 140-159 160 Points Points if Untreated if Treated 0 0 0 1 1 2 1 2 2 3 Step 6: Adding Up the Points Age Total cholesterol HDL-cholesterol Systolic blood pressure Smoking status Point total Step 7: CHD Risk Point Total 10-Year Risk Risk <0 <1% 0 1% 1 1% 2 1% 3 1% 4 1% 5 2% 6 2% 7 3% 8 4% 9 5% 10 6% Point Total 10-Year 11 12 13 14 15 16 17 8% 10% 12% 16% 20% 25% 30%
Step 2: Total Cholesterol TC Points at at Points at (mg/dL) Age 20-39 70-79 <160 0 160-199 4 200-239 7 240-279 9 280 11 Step 3: HDL-Cholesterol HDL-C (mg/dL) 60 50-59 40-49 <40 Points -1 0 1 2 Points at Points at Points
Age 40-49 Age 50-59 Age 60-69 Age 0 3 5 6 8 0 2 3 4 5 0 1 1 2 3 0 0 0 1 1
Step 5: Smoking Status at
Note: Risk estimates were derived the Framingham Heart Study, 5 3 a predominantly Caucasian population in Massachusetts, USA. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.
70-79 Nonsmoker 0 from the experience8of Smoker
Points at Points at Age 20-39
Points at
Points at
Points
Age 40-49 Age 50-59 Age 60-69 Age 0 0 0 1 0 1
Assessing CHD Risk in Women

Step 1: Age Years Points 20-34 -7 35-39 -3 40-44 0 45-49 3 50-54 6 55-59 8 60-64 10 65-69 12 70-74 14 75-79 16 Step 2: Total Cholesterol TC Points at at Points at (mg/dL) Age 20-39 70-79 <160 0 160-199 4 200-239 8 240-279 11 280 13 Step 3: HDL-Cholesterol HDL-C (mg/dL) 60 50-59 40-49 <40 Points -1 0 1 2 Step 4: Systolic Blood Pressure Systolic BP (mm Hg) <120 120-129 130-139 140-159 160 Points Points if Untreated if Treated 0 0 1 3 2 4 3 5 4 6 Step 6: Adding Up the Points Age Total cholesterol HDL-cholesterol Systolic blood pressure Smoking status Point total Step 7: CHD Risk Point Total 10-Year Risk Risk <9 <1% 9 1% 10 1% 11 1% 12 1% 13 2% 14 2% 15 3% 16 4% 17 5% 18 6% 19 8% Point Total 10-Year 20 21 22 23 24 25 11% 14% 17% 22% 27% 30%
Points at
Points at
Points
Age 40-49 Age 50-59 Age 60-69 Age 0 3 6 8 10 0 2 4 5 7 0 1 2 3 4 0 1 1 2 2
Step 5: Smoking Status at
7 4 Note: Risk estimates were derived the Framingham Heart Study, a predominantly Caucasian population in Massachusetts, USA.
70-79 Nonsmoker 0 Smoker from the experience9of
Points at Points at Age 20-39
Points at
Points at
Points
Age 40-49 Age 50-59 Age 60-69 Age 0 0 0 2 0 1
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.
Step 1: Age
Men
Years
20-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79
Women
Points
-9 -4 0 3 6 8 10 11 12 13
Years
20-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79
Points
-7 -3 0 3 6 8 10 12 14 16
Step 2: Total Cholesterol

Men TC
at (mg/dL) 70-79 <160 160-199 200-239 240-279 280 Points at Age 20-39 0 4 7 9 11 Points at Age 40-49 0 3 5 6 8 Points at Age 50-59 0 2 3 4 5 Points at Points Age 60-69 0 1 1 2 3 Age 0 0 0 1 1
Women
79
TC (mg/dL)
<160 160-199 200-239 240-279 280
Points at Age 20-39

0 4 8 11 13
Points at Age 40-49

0 3 6 8 10
Points at Age 50-59

0 2 4 5 7
Points at Points at Age 60-69 Age 700 1 2 3 4 0 1 1 2 2
Note: TC and HDL-C values should be the average of at least two fasting lipoprotein measurements. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.
Step 3: HDL-Cholesterol
Men
HDL-C (mg/dL) 60 50-59 40-49 <40 Points -1 0 1 2
Women
HDL-C (mg/dL) 60 50-59 40-49 <40 Points -1 0 1 2
Note: HDL-C and TC values should be the average of at least two fasting lipoprotein measurements. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.
Step 4: Systolic Blood Pressure

Men
Systolic BP Points (mm Hg) if Untreated <120 0 120-129 0 130-139 1 140-159 1 160 2 Points if Treated 0 1 2 2 3
Women
Systolic BP (mm Hg) <120 120-129 130-139 140-159 160 Points Points if Untreated if Treated 0 0 1 3 2 4 3 5 4 6
Note: The average of several BP measurements is needed for an accurate measurement of baseline BP. If an individual is on antihypertensive treatment, extra points are added. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.
Men
at
Step 5: Smoking Status

Points at Points at Points at Age 20-39 Age 40-49 0 8 Points at 0 5 Points at Age 50-59 0 3 Points at Age 50-59 0 4
Points at Points Age 60-69 0 1 Age 0 1
70-79 Nonsmoker Smoker
Women
at 70-79 Nonsmoker Smoker Points at Points Age 60-69 0 2 Age 0 1 Age 20-39 Age 40-49 0 9 0 7
Note: Any cigarette smoking in the past month. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.
Step 6: Adding Up the Points (Sum From Steps 15)

Age Total cholesterol HDL-cholesterol Systolic blood pressure Smoking status Point total
Step 7: CHD Risk for Men

Point Total Risk <0 0 1 2 3 4 5 6 7 8 9 10 10-Year Risk <1% 1% 1% 1% 1% 1% 2% 2% 3% 4% 5% 6% Point Total 11 12 13 14 15 16 17 10-Year 8% 10% 12% 16% 20% 25% 30%
Note: Determine the 10-year absolute risk for hard CHD (MI and coronary death) from point total. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.
Examination:
Presentation
Height: 6 ft 2 in Weight: 220 lb (BMI 28 kg/m2) Waist circumference: 41 in BP: 150/88 mm Hg P: 64 bpm RR: 12 breaths/min
Cardiopulmonary exam: normal Laboratory results:

TC: 220 mg/dL HDL-C: 36 mg/dL LDL-C: 140 mg/dL TG: 220 mg/dL FBS: 120 mg/dL
What is WJCs 10-year absolute risk of fatal/nonfatal MI?

A 12% absolute risk is derived from points assigned in Framingham Risk Scoring to:
Age: 6 TC: 3 HDL-C: 2 SBP: 2 Total: 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 Women

Point Total Risk <9 9 10 11 12 13 14 15 16 17 18 19 10-Year Risk <1% 1% 1% 1% 1% 2% 2% 3% 4% 5% 6% 8% Point Total 20 21 22 23 24 25 10-Year 11% 14% 17% 22% 27% 30%
Note: Determine the 10-year absolute risk for hard CHD (MI and coronary death) from point total. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.
CHD Risk Equivalents

Risk for major coronary events equal to that in established CHD 10-year risk for hard CHD >20%
Hard CHD = myocardial infarction + coronary death
Diabetes as a CHD Risk Equivalent

10-year risk for CHD 20% High mortality with established CHD
High mortality with acute MI High mortality post acute MI
CHD Risk Equivalents
Other clinical forms of atherosclerotic disease (peripheral arterial disease, abdominal aortic aneurysm, and symptomatic carotid artery disease) Diabetes Multiple risk factors that confer a 10year risk for CHD >20%
Framingham 10-year Total CVD Risk Algorithm (DAgostino et al 2008)
International Comparisons in CVD Morbidity and Mortality

CVD accounts for 25-45% of deaths among different countries CVD death rates (per 100,000) range from 1310 in Russia to 201 in Japan (6.5 fold difference) in men and from 581 in Russia to 84 in France (7-fold difference) USA ranks 16th for both men (413) and women (201)
Secular Trends in CHD and Stroke Mortality

From 1985-1992, greatest annual decline (6-7%) in CHD seen in Israel among men and France among women, USA intermediate (4%), increases in Poland and Romania. Stroke death rates declined most in Australia, Italy, and France (8-9%), USA about 3%.
Age-Adjusted Death Rates for Coronary Heart Disease by Country and Sex, Ages 35-74, 1999
Age-Adjusted to European Standard Data for 1999 unless noted Source: NHLBI 2002 Chart Book on Cardiovascular, Lung, and Blood Diseases
Age-Adjusted Death Rates for Stroke by Country and Sex, Ages 35-74, 1999
Age-Adjusted to European Standard Data for 1999 unless noted Source: NHLBI 2002 Chart Book on Cardiovascular, Lung, and Blood Diseases
Change in Age-Adjusted Death Rates for Coronary Heart Disease by Country and Sex, Ages 35-74, 1990-1999
Men
Women
Age-Adjusted to European Standard Latest data year note in parentheses
Change in Age-Adjusted Death Rates for Stroke by Country and Sex, Ages 35-74, 1990-1999
Men
Women
Age-Adjusted to European Standard Latest data year note in parentheses Source: NHLBI 2002 Chart Book on Cardiovascular, Lung, and Blood Diseases
Migrant Studies
Ni-Hon-San Study showed Japanese living in Japan to have the lowest cholesterol levels and lowest rates of CHD, those living in Hawaii to have intermediate rates for both, and those living in San Francisco to have the highest cholesterol levels and CHD incidence
Pyramid of Risk
(Werner et al. Canadian Journal of Cardiology 1998; 14(Suppl) B:3B-10B)
Approaches to Primary and Secondary Prevention of CVD

Primary prevention involves prevention of onset of disease in persons without symptoms. Primordial prevention involves the prevention of risk factors causative o the disease, thereby reducing the likelihood of development of the disease. Secondary prevention refers to the prevention of death or recurrence of disease in those who are already symptomatic
Risk Factor Concepts in Primary Prevention

Nonmodifiable risk factors include age, sexc, race, and family history of CVD, which can identify high-risk populations Behavioral risk factors include sedentary lifestyle, unhealthful diet, heavy alcohol or cigarette consumption. Physiological risk factors include hypertension, obesity, lipid problems, and diabetes, which may be a consequence of behavioral risk factors.
Population vs. High-Risk Approach

Risk factors, such as cholesterol or blood pressure, have a wide bell-shaped distribution, often with a tail of high values. The high-risk approach involves identification and intensive treatment of those at the high end of the tail, often at greatest risk of CVD, reducing levels to normal. 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 average risk group. Significant reduction in the population burden of CVD can occur only from a population approach shifting the entire population distribution to lower levels.
Expected Shifts in Cholesterol Distribution from High-Risk, Population, and Combined Approaches
Population and CommunityWide CVD Risk Reduction Approaches

Populations with high rates of CVD are those with Western lifestyles of high-fat diets, physical inactivity, and tobacco use. Targets of a population-wide approach must be these behaviors causative of the physiologic risk factors or directly causative of CVD. Requires public health services such as surveillance (e.g.,BFRSS), education (AHA, NCEP), organizational partnerships (Singapore Declaration), and legislation/policy (Anti-Tobacco policies) Activities in a variety of community settings: schools, worksites, churches, healthcare facilities, entire communities
A conceptual framework for public health practice in CVD prevention.
(From Pearson et al., J Public Health. 2001; 29:69 78)
Communitywide CVD Prevention Programs

Stanford 3-Community Study (1972-75) showed mass media vs. no intervention in high-risk residents to result in 23% reduction in CHD risk score North Karelia (1972-) showed public education campaign to reduce smoking, fat consumption, blood pressure, and cholesterol Stanford 5-City Project (1980-86) showed reductions in smoking, cholesterol, BP, and CHD risk Minnesota Heart Health Program (1980-88) showed some increases in physical activity and in women reductions in smoking
Materials Developed for US Community Intervention Trials

Mass media, brochures and direct mail Events and contests Screenings Group and direct education School programs and worksite interventions Physician and medical setting programs Grocery store and restaurant projects Church interventions Policies
Individual and High-Risk Approaches

Primary Prevention Guidelines (1995) and Secondary Prevention Guidelines (Revised 2001) released by the American Heart Association provide advice regarding risk factor assessment, lifestyle modification, and pharmacologic interventions for specific risk factors Barriers exist in the community and healthcare setting that prevent efficient risk reduction Surveys of CVD prevention-related services show disappointing results regarding cholesterollowering therapy, smoking cessation, and other measures of risk reduction

CVD Definitions and Statistics Jan 2012

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Cardiovascular Epidemiology and Prevention

Nathan D. Wong, PhD, FACC, FAHA

Cardiovascular Epidemiology: Definitions, Concepts, Historical Perspectives and Statistics

350,000 292,857 270,018

Trends in cardiovascular procedures, United States: 19792009

0 1979 1980 1985 1990 Years 1995 2000 2005 2009

50.6 34.3 22.5

Roger VL et al. Published online in Circulation Dec. 15, 2011

Total Dollars (in Billions)

153.2 121.1 132.4

0 All CVD Hypertension CHD HF Stroke Other CVDs

Unpublished data tabulated by AHA using methods described in Circulation. 2011;123:933944.

500 450 400 350 79 80 85 90 Years Males Females 95 00 06

Deaths due to diseases of the heart (United States: 19002008)

Source: National Center for Health Statistics.

800 600 400 200

350,000 295,259 270,210 Deaths 250,000

Prevalence of stroke by age and sex (NHANES: 20052008)

Roger VL et al. Published online in Circulation Dec. 15, 2011

Prevalence of stroke by age and sex (NHANES: 20052008).

Source: NCHS and NHLBI.

600 500 400 300 200 100 0 79 80 85 90 Years Male Female 95 00 06

Development of Atherosclerotic Plaques

Foam cells Fibrous cap

Ross R. Nature. 1993;362:801-809.

Raised lesions 30 Fatty streaks 20 10 0

Intimal surface (%)

15-19 20-24 25-29 30-34 White

15-19 20-24 25-29 30-34 White

15-19 20-24 25-29 30-34 Black

Most Myocardial Infarctions Are Caused by Low-Grade Stenoses

Falk E et al, Circulation, 1995.

Atherosclerotic Plaque Rupture and Thrombus Formation

Features of a Ruptured Atherosclerotic Plaque

Constantinides P. Am J Cardiol. 1990;66:37G-40G.

Vulnerable Versus Stable Atherosclerotic Plaques

Stable Plaque Lumen

Libby P. Circulation. 1995;91:2844-2850.

Concept of cardiovascular risk factors

Age, sex, hypertension, hyperlipidemia, smoking, diabetes, (family history), (obesity)

Kannel et al, Ann Intern Med 1961

Major Risk Factors

Other Recognized Risk Factors

2011 American Heart Association, Inc. All rights reserved.

Roger VL et al. Published online in Circulation Dec. 15, 2011

2011 American Heart Association, Inc. All rights reserved.

Roger VL et al. Published online in Circulation Dec. 15, 2011

Lifetime Risk of Coronary Heart Disease in the Framingham Study

At age 40 years: 48.6% At age 70 years: 34.9%

First Coronary Events: Framingham Study

Percent as Specified Event

Angina Pectoris Men Women

Sudden Death Men Women

Framingham Study 44 year follow-up.

Source: Circulation 1998;97:1837-1847.

Systolic BP* Diabetes Cigarettes Prior Atrial Fib. Prior CVD

D 130-148 Yes Yes No No

E 130-148 Yes Yes Yes No

F 130-148 Yes Yes Yes Yes

Source: Stroke 1991;22:312-318.

*BP in millimeters of mercury (mmHg)

Offspring CVD Risk by Parental CVD Status: Framingham Study

Parental CVD <55 men, <65 Women NONE MATERNAL PATERNAL

Lifetime Risk of CHD Increases with Serum Cholesterol

_________________________________________________________________ Subjects 35-64 36-year Follow-up P<.001,*P<.0001