Epidemiology and Prevention of Coronary Artery Disease

Martha Gulati MD, MS, FACC, FAHAAssociate Professor of Medicine and Clinical Public HealthSection Director of Women’s Cardiovascular Health and Preventive Cardiology Director, Cardiac Rehabilitation Ohio State University

Learning Objectives

Describe primary and secondary prevention strategies to reduce cardiovascular disease risk

Describe non-modifiable and modifiable risk factors that impact the risk of cardiovascular disease (CVD)

Describe examples of currently accepted “best practice” guidelines for the treatment of cardiovascular disease

Identify behaviors that impact cardiovascular health

Source: NCHS and NHLBI. A indicates CVD plus congenital CVD; B, cancer; C, accidents; D, CLRD; E, diabetes; and F, Alzheimer's disease.

Mozaffarian D et al. Circulation. 2015;131:e29-e322

CVD Compared with other Causes of Death for all males and females (United States: 2011)

What is Prevention

Primordial prevention reduces the appearance of the mediating risk factors in the population, aiming to modify the conditions that generate and structure the unequal distribution of health-damaging exposures, susceptibilities among the population

Example: Ban on trans fats in NYC restaurants/ Smoking Bans in Bars

Primary prevention alters the levels of mediating risk factors after they appear in the population, focusing on individuals or groups of individuals and aiming to modify those factors that lead to an increased risk of CVD Intervening on a risk factor before the disease is clinically evident

Example: Treating hypertension or elevated LDL cholesterol in an asymptomatic individual with increased risk of future development of CAD

Secondary prevention alters risk factors related to disease after disease present Intervening on a risk factor or disease after the disease is clinically evident

Example: Use of statin therapy post MI

Risk Factors for the Development of Coronary Artery Disease Non-modifiable

Age Race Family history/Genetics

1st degree male relative with heart disease <55 1st degree female relative with heart disease <65

Risk Factors for the Development of Coronary Artery Disease Modifiable/preventable

Smoking Hypertension Hyperlipidemia Obesity Diabetes/Metabolic Syndrome Poor Fitness/Sedentary lifestyle Lack of Sleep

Smoking causes more arterial damage in Women vs Men

Deaths due to smoking now equal to men (women smoke more & start younger)

“Social” smoking (1-4/day) kills

• 50% death

• 290% heart disease

• 500% lung cancer

Secondhand Smoking:

• Increases risk of CVD by 25-30%

Electronic Cigarettes

Thun MJ et al. NEJM 2013;368:351

vs never smokers

Tobacco and CVD

Sleep and CVD

Sleeping <5 hours of sleep/night is associated with risk of CAD vs getting >5 hours of sleep

Each additional hour of sleep = lowering systolic blood pressure by ~17mm Hg

Study of ~10,000 adults, aged 32-49 years who sleep <7 hours/night are more likely to be obese

Insufficient sleep linked to increased risk for heart disease, colon cancer, breast cancer and diabetes

JAMA. 2008;300(24):2859-2866

Prevalence of Hypertension* NHANES 2005-2008

20-34 35-44 45-54 55-64 64-74 75+0

10

20

30

40

50

60

70

80

90

100

11.1

25.1

37.1

54.0

64.0 66.7

6.8

19.0

36.2

53.3

69.3

78.5Men

Women

Age, years

Pe

rce

nt

of

Po

pu

lati

on

* Defined as systolic blood pressure >140 mm Hg or diastolic blood pressure >90 mm Hg, taking antihypertensive medication, or being told twice by a physician or other professional that one has hypertension.

Circulation. 2012;125::e12-e230 .

NH White

Men

NH White

Wom

en

NH Bla

ck M

en

NH Bla

ck W

omen

Mex

ican

Am

eric

an M

en

Mex

ican

Am

eric

an W

omen

0

5

10

15

20

25

30

35

40

45

50

25.6

22.9

37.5 38.2

26.9

25.0

28.3 28.2

38.641.5

25.7 26.8

30.5

27.7

40.242.9

24.6 25.0

1988-1994 1999-2004 2005-2008

Per

cen

t o

f P

op

ula

tio

n

Source: NCHS and NHLBI. NH indicates non-Hispanic.

Roger VL et al. Published online in Circulation Dec. 15, 2010

Prevalence Trends for HTN in Adults by race ethnicitysex NHANES:1988-1994, 1999-2004, 2005-2008

Blood Pressure

DASH Diet: Dietary Approach to Stop Hypertension Fruits and Vegetables (9+) Whole grains Low-fat dairy (1) Low meat, fish, fowl (1) Low sat./total fat, cholesterol K+ and Ca++ rich Calorie neutral, 3 gm Na+

DASH Study

48% women ( BP 133/85mmHg) 60% African Americans > 60% obese BP Results:

• ¯ 6.4/2.9 mmHg overall• Greater drop in African Americans and

higher baseline BP

Svetkey, Archives Int Med, 1999

Modification Recommendation Avg SBP ReductionWeight Normal body wt 5-20 mm Hg/10 kgreduction (BMI 18-5-24.9 kg/m2)DASH eating fruits, vegetables, and 8-14 mm Hgplan low-fat diary

saturated and total fatDietary Na+ sodium intake to 2-8 mm Hgsodium 100 mmol per day reduction (2.4 g Na+ or 6 g NaCI)Aerobic Regular aerobic physical 4-9 mm Hgphysical activity (eg, brisk walking)activity at least 30 min/d, most

days of the weekModerate Men: Limit to 2 drinks/day 2-4 mm Hgalcohol Women and lighter weight consumption persons: Limit to 1 drink/day

21-55 mm HgJNC VII

Effects of Lifestyle on Blood Pressure

Sex Differences in Aspirin for Primary CVD Prevention Meta-analysis; 6 RCT’s, n = 95,456, 51,342 women Total CVD risk reduction:

Men: ↓14%, (↓32% MI, ↔ stroke) Women: ↓12%, (↓17% stroke, ↔ MI)

No effect on CVD mortality Equal bleeding risk (↑~70%)

Berger et al, JAMA 295:306

Physical Activity and Mortality: Harvard Alumni Study

Paffenbarger RS et al. NEJM 1986;314:605-13

Men Women0

5

10

15

20

25

30

35

40

45

40.1

36.236.0

24.1

29.7

25.9

NH White NH Black Hispanic

Per

cen

t o

f P

op

ula

tio

n

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.

©2010 American Heart Association, Inc. All rights reserved. Roger VL et al. Published online in Circulation Dec. 15, 2010

Prevalence of regular leisure-time physical activity among adults older than 18 years of age

by race ethnicity and sex (NHIS: 2009).

Recommend Daily Moderate-Intense Activity for ~30 minutes

Obesity (BMI ≥30 kg/m2)

Diabetes

1994

1994

2000

2000

No Data <14.0% 14.0-17.9% 18.0-21.9% 22.0-25.9% >26.0%

No Data <4.5% 4.5-5.9% 6.0-7.4% 7.5-8.9% >9.0%

CDC’s Division of Diabetes Translation. National Diabetes Surveillance System available at http://www.cdc.gov/diabetes/statistics

2010

2010

Age-Adjusted Prevalence of Obesity and Diagnosed Diabetes Among U.S. Adults Aged 18 Years or older

NH White Males NH White Females

NH Black Males NH Black Females

Hispanic Males Hispanic Females

0

5

10

15

20

25

13.913.2

18.7

23.3

19.7 19.5

13.8

6.2

17.5

12.6

18.9

11.1

Overweight Obese

Per

cen

t o

f P

op

ula

tio

n

Source: Youth Risk Behavior Surveillance—United States, 2009. Table 90. NH indicates non-Hispanic.

©2010 American Heart Association, Inc. All rights reserved. Roger VL et al. Published online in Circulation Dec. 15, 2010

Prevalence of overweight and obesity among students in grades 9–12 by sex and race/ethnicity (YRBS: 2009).

People Without Diabetes250.4 Million

Diabetes in the United States

• Incidence: 798,000 New cases per year• 90-95% of Diabetes is Type 2 Diabetes

Metabolic Syndrome: Diagnostic Criteria

Abdominal obesity Waist circumference men > 40 in Waist circumference women > 35 in

Triglycerides > 150 mg/dL HDL

Men < 40 mg/dL

Women < 50 mg/dL BP > 130/85 Fasting glucose > 110 mg/dL

(Any 3 of 5 would meet diagnostic criteria)

Patients with Diabetes

Risk of Cardiac Events in Patients With Diabetes

109

20

11

9 63819

3*

30

0

2

4

6

8

10

Age-adjusted annual rate/1,000

Men Women

Total CVD

CHD Cardiac failure

Intermittent claudication

Stroke

Riskratio

Risk to Women with Diabetes for all types of CVD Events (except stroke) is greater than MenP<0.001 for all values except *P<0.05.Wilson PWF, Kannel WB. In: Hyperglycemia, Diabetes and Vascular Disease. Ruderman N et al, eds. Oxford; 1992.

Age-adjusted Risk

Cardiovascular Event Men Women

Coronary Disease 1.52.2

Stroke 2.92.6

Peripheral Artery Disease 3.46.4

Cardiac Failure 4.4 7.8

All CVD Events 2.2 3.7

Women vs Men

Sex Differences in Type I Diabetes and Risk of Death

26

26 studies: 214,114 individuals and 15,273 events

Women with Type 1 DM have ~40% greater excess risk of all-cause mortality, 2X excess risk of fatal and nonfatal vascular events compared with men with Type 1 DM

Mor

tality

Stroke

Renal

Diseas

e

Fatal

CVD

Incid

ent C

AD0

0.5

1

1.5

2

2.5

3

1.37 1.37 1.441.86

2.54

Risk Women:Men

Huxley RR et al. Lancet Diabetes Endocrinol. 2015;doi:10.1016/s2213-8587(14)70248-

CHD Risk Increases as Plasma Cholesterol Increases

NH White NH Black Mexican American180

185

190

195

200

205

210

206

204205

203

198

201

198

192

201

1988-94 1999-2004 2005-2008

Mea

n S

eru

m T

ota

l C

ho

lest

ero

l

Source: NCHS and NHLBI. NH indicates non-Hispanic.

©2010 American Heart Association, Inc. All rights reserved. Roger VL et al. Published online in Circulation Dec. 15, 2010

Trends in mean total serum cholesterol among adults ages equal or greater than 20 by race and survey year

(NHANES: 1988–1994, 1999–2004 and 2005–2008)

ASCVD Risk Calculator (APP for that)

• For those 20-59 risk estimator provides lifetime risk estimate

• This is intended to drive discussions ofgreater adherence to heart-healthy lifestyle

• Part of risk discussion

Statin Benefit Groups

Secondary Prevention LDL-C ≥ 190 mg/dL

Diabetes – 40 to 75 yrsLDL-C 70-189 mg/dl

Primary Prevention – 40 to 75 yrs

LDL-C 70-189 mg/dlASCVD Risk ≥ 7.5 %

Rx: Moderate intensity or high intensity statin

Statin Rx not automatic,requires clinician-patient discussion

Rx: Optimal benefit with high intensity statins lower LDL-C ≥ 50%Use moderate intensity if age >75 or can’t tolerate high intensity

Statin Effects on Major Vascular Events

CTT. Lancet 2008 371: 117-125

EndpointEvents (%)

Treatment Control Rate Ratio (CI)

Non-fatal MI 2001 (4·4) 2769 (6·2) 0·74 (0·70 – 0·79)CHD death 1548 (3·4) 1960 (4·4) 0·81 (0·75 – 0·87)

Any major coronary event 3337 (7·4) 4420 (9·8) 0·77 (0·74 – 0·80)

CABG 713 (3·3) 1006 (4·7) 0·75 (0·69 – 0·82)PTCA 510 (2·4) 658 (3·1) 0·79 (0·69 – 0·90)Unspecified 1397 (3·1) 1770 (3·9) 0·76 (0·69 – 0·84)

Any coronary revascularisation 2620 (5·8) 3434 (7·6) 0·76 (0·73 – 0·80)

Haemorrhagic stroke 105 (0·2) 99 (0·2) 1·05 (0·78 – 1·41)Presumed ischaemic stroke 1235 (2·8) 1518 (3·4) 0·81 (0·74 – 0·89)

Any stroke 1340 (3·0) 1617 (3·7) 0·83 (0·78 – 0·88)

Any major vascular event 6354 (14·1) 7994 (17·8) 0·79 (0·77 – 0·81)

0·5 1·0 1·5

Favors statin

24.533.8 31.7

76.8

15.0 17.18.2

3.2

32.9

23.2

22.9

38.441.2

30.4

72.2

33.2

45.2 46.641.7

61.4

0.0

20.0

40.0

60.0

80.0

100.0

CurrentSmoking

Body MassIndex

PhysicalActivity

Healthy DietScore

TotalCholesterol

BloodPressure

FastingPlasmaGlucose

Pe

rce

nta

ge

Poor Intermediate Ideal

©2010 American Heart Association, Inc. All rights reserved. Roger VL et al. Published online in Circulation Dec. 15, 2010

Prevalence Estimates for poor, intermediate and ideal CV Health for Metrics of CVD Health based on AHA 2020 goalsUS adults >20 years of age, NHANES 2005-2006 (data as of 1/1/2010

AHA/ACC Secondary Prevention Guidelines:

33

All Patients Should Receive Therapy:• Smoking cessation• Anti-platelet therapy• Beta blocker post-MI or with LV dysfunction• ACE-inhibitor (or ARB) if post-MI or LVEF 40%

• Add aldosterone blockade if CHF• Statin • Weight loss of 5-10% if BMI ≥ 30 kgm2

• Physical activity at least 30 minutes per day• Cardiac Rehabilitation- Angina/Post MI/ Post-stent/ Post valve

surgery/Heart Failure• Influenza vaccine

Aspirin

Clopidogrel

Beta-Blocker

Ace Inhibitor

HMG-CoA Reductase Inhibitor: Secondary Prevention

Effects of Cardiac Rehabilitation

Outcome Mean 95% conf. intervals p-value

Total Mortality* -20% (-7 to -32%) p=.005 Cardiac Mortality* -26% (-10 to -29%) p=.002 Nonfatal MI -21% (-43 to 9%) p=.15 CABG -13% (-35 to 16%) p=.4 PCI -19% (-51 to 34%) p=.4

Taylor, et al Am J of Medicine 2004; 116:682-97

Exercise for 2° CHD Prevention: Why?

Improved functional capacity Improved CAD risk factor control Reduced depression Improved survival

Though originally designed for coronary artery disease patients, there is accumulating evidence that patients with other cardiac diseases will also benefit from cardiac rehabilitation

Medication Adherence after MI

Statins: 75% at discharge, 44% 3 years BB: 84% at discharge, 48% at 3 years ACEI: 62% at discharge, 43% at 3 years

Am J Med. 2009 Oct;122(10):961.e7-13.

Medication Adherence with Cardiac Rehabilitation All patients, not just post-MI

Squires et al, JCRP 2008;28:180-186

Cardiovascular Prevention

Broad implementation of preventive recommendations can reduce the epidemic of cardiovascular disease

Patient and community education, screening of cardiovascular risk factors with implementation of appropriate interventions, in addition to further research to improve our understanding of the atherosclerotic process will be necessary to make significant impact

Risk assessment tools are available to identify individuals who may benefit from more aggressive approaches, including both therapeutic lifestyle changes and pharmacologic agents

It will require the coordinated efforts of public health experts, primary care physicians and cardiovascular specialists to further impact the incidence of cardiovascular diseases and its associated morbidity and mortality

Prevention of Heart Disease Quiz

Thank you for completing this module

If you have any questions or would like to offer me some feedback, please contact me:

Martha.Gulati@osumc.edu

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