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Prevention of Prevention of Cardiovascular Diseases Cardiovascular Diseases

inin populationpopulation

Lecturer Lecturer MDMD, Ph.D. Furdela , Ph.D. Furdela Victoria Victoria

Assistant Assistant Professor,Professor, Pediatric Pediatrics s Department #2, Ternopil State Department #2, Ternopil State

Medical University, UkraineMedical University, Ukraine

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OutlineOutline

World status of CVDsWorld status of CVDs

Prevention efficacyPrevention efficacy

Recommendations re risk factorsRecommendations re risk factors

Role of CV specialist in preventionRole of CV specialist in prevention

1999 WHF "Impending Global Pandemic of CVDs

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World Status of CVDWorld Status of CVD

Represents 30% of all deaths Represents 30% of all deaths

worldwide (15 million deaths/year)worldwide (15 million deaths/year)

Leading cause of death and disabilityLeading cause of death and disability

CVD burden CVD burden in developing countries in developing countries

Risk factors Risk factors worldwide worldwide

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Preceding FactsPreceding Facts

Defined Risk Factors in adults Defined Risk Factors in adults associated with accelerated associated with accelerated atherosclerosis and CVD ratesatherosclerosis and CVD rates

Atherosclerosis begins in childhood Atherosclerosis begins in childhood Extent of atherosclerosis in children Extent of atherosclerosis in children

correlated with same risk factors as correlated with same risk factors as in adults in adults

Development of Development of atherosclerosis atherosclerosis and its and its complications complications during human during human lifelife

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0

20

40

60

80

%

Age (Years)

Aorta Coronary Arteries

2-15 16-20 21-25 26-39 2-1516-20 21-2526-39

p = 0.001 for trend toward increasing prevalence with age in aorta

and coronary arteries.

Early Appearance of Atherosclerosis: Early Appearance of Atherosclerosis: Bogalusa Heart StudyBogalusa Heart Study

Prevalence of Fibrous Plaque Lesions

0

20

40

60

80

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The EvidenceThe Evidence physical activity associated with physical activity associated with life life

expectancyexpectancy Direct association between obesity & Direct association between obesity &

insulin resistance in childreninsulin resistance in children Direct association between obesity & lipid Direct association between obesity & lipid

levels in childrenlevels in children Tracking: BMI>weight>skinfold Tracking: BMI>weight>skinfold

thicknesses>lipids>BPthicknesses>lipids>BP Clusters of multiple risk factors persist Clusters of multiple risk factors persist

strongly from child-to-adulthoodstrongly from child-to-adulthood

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Risk Factors for Risk Factors for AtherosclerosisAtherosclerosis

SmokingSmoking ObesityObesity High blood pressureHigh blood pressure Physical InactivityPhysical Inactivity High blood fat levelsHigh blood fat levels DiabetesDiabetes Positive family historyPositive family history Other (ethnicity, anger)Other (ethnicity, anger)

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RecommendationsRecommendations

Cardiovascular Health in Childhood Cardiovascular Health in Childhood (AHA Scientific Statement)(AHA Scientific Statement) Circ 2002;106:143-160Circ 2002;106:143-160 Circ 2002;107:1562-1566Circ 2002;107:1562-1566

Canadian Cardiovascular Society Canadian Cardiovascular Society Consensus Conference on Consensus Conference on Prevention of CVD: The Role of the Prevention of CVD: The Role of the CV SpecialistCV Specialist CJC 1999;15(supple.G)CJC 1999;15(supple.G)

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TobaccoTobacco

Complete cessation for those who Complete cessation for those who

smokesmoke

No exposure to environmental No exposure to environmental

tobacco smoketobacco smoke

No new initiation of cigarette No new initiation of cigarette

smoking or tobacco usesmoking or tobacco use

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ObesityObesity

Appropriate body weight (BMI for age)Appropriate body weight (BMI for age)

Overall healthy eating pattern (limit Overall healthy eating pattern (limit

salt, fat, calories & sugar > 2 years salt, fat, calories & sugar > 2 years

age)age)

Balance “Energy in = energy out” for Balance “Energy in = energy out” for

weightweight

Begin treatment before adolescenceBegin treatment before adolescence

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13

2020

1515

1010

55

00

6-11 yrs 12-19 yrs

1963-70 1971-74 1976-80 1988-94 1999

Trends in prevalence of overweight in USA(CDC – NHANES)

%

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Physical ActivityPhysical Activity

Physical activity every day (60 Physical activity every day (60

minutes per day for children)minutes per day for children)

Reduce/limit sedentary time Reduce/limit sedentary time

(e.g.. TV maximum 2 hours per (e.g.. TV maximum 2 hours per

day)day)

May add resistance training to May add resistance training to

aerobic activity in adolescentsaerobic activity in adolescents

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Lipids & LipoproteinsLipids & Lipoproteins

Total cholesterolTotal cholesterol <4.4 mmol/L <4.4 mmol/L

recommended (USA>170mg/dL borderline; recommended (USA>170mg/dL borderline;

>200 mg/dL is >200 mg/dL is ))

LDL-CLDL-C <2.85 mmol/L recommended <2.85 mmol/L recommended

(USA<110mg/dL)(USA<110mg/dL)

TriglyceridesTriglycerides <1.5 mmol/L recommended <1.5 mmol/L recommended

(USA <150 mg/dL)(USA <150 mg/dL)

HDL-CHDL-C >35 mg/dL recommended >35 mg/dL recommended

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CAD Death Rate per 10,000 Person-years

100+ 90-99

80-89

75-79

70-74

<70<120

120-139140-159

160+

Diastolic BP (mmHg)Systolic BP (mmHg)

20.610.3 11.8 8.8 8.5 9.2

11.8

12.6

12.8

13.9

24.6

25.3

25.2

24.9

16.9

23.8

31.0

25.8

34.7

43.8

38.1

80.6

37.4

48.3

Effect of SBP and DBP onEffect of SBP and DBP onAge-Adjusted CAD Mortality: Age-Adjusted CAD Mortality:

MRFITMRFIT

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Blood PressureBlood Pressure

Systolic & diastolic BP>90Systolic & diastolic BP>90thth% for age, % for age,

sex and height is abnormalsex and height is abnormal ((

www.nhlbi.nih.gov/health/prof/heart/hbp/hbpwww.nhlbi.nih.gov/health/prof/heart/hbp/hbp

_ped.htm_ped.htm

.).)

>130/~80 is almost always pathological >130/~80 is almost always pathological

in youth.in youth.

Use proven effective therapies Use proven effective therapies

recommended for adults (CPGs)recommended for adults (CPGs)

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DiabetesDiabetes Adequate nutrition (neither over Adequate nutrition (neither over

nor undernutrition) of pregnant nor undernutrition) of pregnant

women: women: Barker hypothesisBarker hypothesis

Limit sugar intakeLimit sugar intake

Maintain normal weight for age & Maintain normal weight for age &

heightheight

For type 1 diabetics, ongoing For type 1 diabetics, ongoing

strict control (Hgb A1c)strict control (Hgb A1c)

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Ethnicity (esp. South Asian / aboriginal/black/Hispanic)

Low socioeconomic level

Social isolation

Depression

Pregnancy (HTN and gestnl diabetes)

“Emerging” risk factors

Other Risk FactorsOther Risk Factors

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Childhood AbuseChildhood Abuse Adverse childhood experiences Adverse childhood experiences

(ACEs)(ACEs)– 1.7x 1.7x risk with emotional abuse risk with emotional abuse– 1.7x 1.7x risk with crime in risk with crime in

householdhousehold– 1.3x 1.3x risk with emotional neglect risk with emotional neglect– 1.3x 1.3x risk with substance abuse risk with substance abuse– Depressed affect OR 2.1Depressed affect OR 2.1– Anger: OR 2.5Anger: OR 2.5– 7 or > ACEs 7 or > ACEs risk almost 4x risk almost 4x

Dong M et al CIRC 110; 2004Dong M et al CIRC 110; 2004

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--

Specialized medicine

First line medicine

Clinical Application of the Concept of Risk

Vascular, unstable

Asymptomatic

VascularDiabetic

Asymptomatic + risk factors

Primary prevention Secondary prevention

Diabetic + risk factors

Pluri-vascular

Lo

wH

igh

Hyp

er

Ris

k

Symptomatic

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Economic Burden of Economic Burden of Coronary Artery Disease (CAD)Coronary Artery Disease (CAD)

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

Direct and Indirect Cost of CAD Country (not adjusted for inflation)

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BMI

<75%ile 75-85%ile85-95%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 alEthnicity & Disease 14;2004

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Role of Cardiovascular Role of Cardiovascular SpecialistSpecialist

EducationEducation of other health care of other health care

personnelpersonnel

AdvocateAdvocate for heart healthy for heart healthy

public policiespublic policies

TreatTreat individual patients, including individual patients, including

children with significant risk factors.children with significant risk factors.

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ConclusionsConclusions

The burden of global CVD is The burden of global CVD is increasingincreasing

The burden of risk factors is rising The burden of risk factors is rising alarmingly in children and youthalarmingly in children and youth

Cardiovascular specialists have an Cardiovascular specialists have an obligation to lead in preventionobligation to lead in prevention

EEducate, ducate, AAdvocate, dvocate, TTreatreat

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Gracias!

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Questions for readers of Questions for readers of Prevention of Cardiovascular Diseases: Prevention of Cardiovascular Diseases:

Begin in Childhood! Begin in Childhood! lecture by lecture by Ruth Ruth Collins-NakaiCollins-Nakai

(developed by Supercourse Team)(developed by Supercourse Team)

• At what age do we begin to see fatty At what age do we begin to see fatty streaks associated with atherosclerosis?streaks associated with atherosclerosis?

•What is the difference in risk from the What is the difference in risk from the lowest to highest risk factorslowest to highest risk factors

•Why should we intervene with children to Why should we intervene with children to prevent MIs 60 years later?prevent MIs 60 years later?