risk factors for stroke and heart attack[2]...cvd risk factors hypertension* cigarette smoking...

RISK FACTORS FOR HEART ATTACK AND STROKE–2010.

Colman Ryan, MD FACC FRCPIClinical Professor of Medicine

University of California, San Francisco, School of MedicineSan Francisco, CAExecutive Director

San Francisco Heart InstituteSeton Medical Center

Daly City, CA

CV Disease and Its Prevailing Risk in the United States

Health Status: United States vs. 29 Other OECD Countries (2)

916.9White men, yearsIceland (18.1)916.8All men, years

1019.8White women, yearsJapan (23)1019.8All women, years

Life expectancy from age 65/-2004*

1975.3White menSweden (78.4)2274.8All men

1980.5White womenJapan (85.3)2280.1All Women

Life Expectancy from birth (y)

Best Rank of OECD

U.S. Rank in OECD (30)

U.S.A.Health Status Measure

* Data missing for six (6) countries

Proportions(Premature Mortality)

Genetic30%

Health care10%

Determinants of Health

Behavior40%

• Genetic predisposition

• Behavioral patterns

• Environmental exposures

• Social circumstances

• Health care

Social15%

Environment5%

Source: McGinnis JM, Russo PG, Knickman, JR. Health Affairs, April 2002.

*

20

8543 29 17

365

0

50

100

150

200

250

300

350

400

450

Behavioral Causes of Annual Deaths in the United States, 2000

Num

ber o

f dea

ths

(thou

sand

s)

Source: Mokdad et al, JAMA 2004;291:1238-1245Mokdad et al; JAMA. 2005; 293:293

Sexual Alcohol Motor Guns Drug Obesity/ SmokingBehavior Vehicle Induced Inactivity

Also suffer from mental illness and/or substance abuse

*

435

CVD disease CVD disease mortality trends for males and femalestrends for males and females(United States: 1979(United States: 1979--2005). 2005). Source: NCHS and NHLBI. Note:Note: No comparability ratios were appliedNo comparability ratios were applied

400

450

500

550

79 80 85 90 95 00 05

Years

Dea

ths

in T

hous

ands

Males Females

AgeAge--adjusted death rates for CHD, stroke, lung and breast adjusted death rates for CHD, stroke, lung and breast cancer for white and black femalescancer for white and black females (United States: 2005).(United States: 2005).Source: NCHS and NHLBI.Source: NCHS and NHLBI.

44.0 41.523.4

60.740.0 32.8

110.0

140.9

0

50

100

150

200

Coronary HeartDisease

Stroke Lung Cancer Breast Cancer

Per 1

00,0

00 P

opul

atio

n

White Females Black Females

Deaths from diseases of the heartDeaths from diseases of the heart (United States: 1900(United States: 1900––2006)2006)Note: See Glossary for an explanation of Note: See Glossary for an explanation of ““Diseases of the Heart.Diseases of the Heart.””Source: NCHS and NHLBI. Source: NCHS and NHLBI.

0

200

400

600

800

1,000

00 10 20 30 40 50 60 70 80 90 00 06

Years

Deat

hs in

Tho

usan

ds

Deaths from cardiovascular diseaseDeaths from cardiovascular disease(United States: 1900(United States: 1900––2006 preliminary). 2006 preliminary). Source: NCHS and NHLBI. Source: NCHS and NHLBI.

0

200

400

600

800

1000

1200

00 10 20 30 40 50 60 70 80 90 00 06

Years

Dea

ths

in T

hous

ands

Hospital discharges for cardiovascular diseases. Hospital discharges for cardiovascular diseases. (United States: 1970(United States: 1970--2006). 2006). Note: Hospital discharges include Note: Hospital discharges include people discharged alive, dead and status unknown. people discharged alive, dead and status unknown. Source: NCHS and NHLBI.Source: NCHS and NHLBI.

0

1

2

3

4

5

6

7

70 75 80 85 90 95 00 06

Years

Dis

char

ges

in M

illio

ns

Percentage breakdown of deaths from cardiovascular diseases Percentage breakdown of deaths from cardiovascular diseases (United States: 2006 preliminary) (United States: 2006 preliminary) * * -- Not a true underlying cause. Not a true underlying cause. Source: NCHS and NHLBI. Source: NCHS and NHLBI.

52

17

7

7

4

14Coronary HeartDiseaseStroke

HF*

High Blood Pressure

Diseases of theArteriesOther

5217

77 4 14

Coronary HeartDiseaseStroke

HF*

High BloodPressureDiseases of theArteriesOther

Heart Failure*

Prevalence of CVD in adults age 20 and older by age and sex Prevalence of CVD in adults age 20 and older by age and sex (NHANES: 2005(NHANES: 2005--2006). 2006). Source: NCHS and NHLBI. Source: NCHS and NHLBI. These data include coronary heart disease, heart failure, strokeThese data include coronary heart disease, heart failure, stroke and hypertension.and hypertension.

15.9

37.9

73.3

7.8

79.385.9

38.5

72.6

0102030405060708090

100

20-39 40-59 60-79 80+

Perc

ent o

f Pop

ulat

ion

Men Women

10.1

21.4

34.6

59.2

4.28.9

74.4

40.2

20.0

65.2

0

10

20

30

40

50

60

70

80

45-54 55-64 65-74 75-84 85-94

Age

Per 1

,000

Per

son

Year

s

Men Women

Incidence of CVDIncidence of CVD** by age and sex. by age and sex. Framingham Heart Study, Framingham Heart Study, 19801980--2003.2003. Source:NHLBISource:NHLBI. . * Includes CHD, HF, stroke or intracerebral * Includes CHD, HF, stroke or intracerebral hemorrhage. Does not include hypertension alone.hemorrhage. Does not include hypertension alone.

CVD deaths vs. cancer deaths by age.CVD deaths vs. cancer deaths by age.(United States: 2005). (United States: 2005). Source: NCHS and NHLBI. Source: NCHS and NHLBI.

2681

258327

5048125

864

2199 138 166

83

559

0

200

400

600

800

1,000

<45 45-54 55-64 65-74 75-84 85+ Total

Ages

Dea

ths

in T

hous

ands

CVD Cancer

CVD and other major causes of death: both sexes.(United States: 2005). Source: NCHS and NHLBI.

0

100,000

200,000

300,000

400,000

500,000

600,000

700,000

800,000

900,000

All Ages <85 85+

Deaths

AlzheimerCLRDCancerOther CVDStrokeHeart Disease

Hypertension: A National Health Crisis

Incidence of Systolic Hypertension Increases With Age

Systolic Blood Pressure Is a More Important Cardiovascular Risk Factor Than Diastolic Blood Pressure

Use of β1-Selective Atenolol and Adverse Outcomes in Patients With Hypertension

1.5

Atenolol vs placebo or no treatment

4 studies included (n=6825)

Atenolol vs other antihypertensive therapy

5 studies included (n=17,671)

Placebo/Other antihypertensive better1.00.5

All-cause mortality

Cardiovascularmortality

Myocardial infarct

Stroke

Relative risk, 95% CIAtenolol betterPrimary outcomes studies in hypertension have not been conducted with COREG CR.Trials included in meta-analysis vs placebo: Treatment of Hypertension in Elderly Patients in Primary Care (HEP); Dutch Transitory Ischemic Attack Trial; Tenormin After Stroke and TIA (TEST); Medical Research Council Trial of Treatment of Hypertension in Older Adults (MRC Old). Trials included in meta-analysis vs other antihypertensive agent: MRC Old; UKPDS; European Lacidipine Study of Atherosclerosis (ELSA); Heart Attack Primary Prevention in Hypertension Trial (HAPPHY); Losartan Intervention for Endpoint Reduction Study (LIFE).Carlberg B, et al. Lancet. 2004;364:1684-1689.

Trends in Adult Smoking, by Sex—U.S., 1955–2004

Trends in cigarette current smoking among persons aged 18 or older

Graph provided by the Centers for Disease Control and Prevention. 1955 Current Population Survey; 1965–2001 NHIS. Estimates since 1992 include some-day smoking.

Perc

ent

70% want to quit70% want to quit

0

10

20

30

40

50

60

1955 1959 1963 1967 1971 1975 1979 1983 1987 1991 1995 1999 2003

Male

Female 23.4%18.5%

20.9% of adults are current

smokers

Year

Prevalence of Adult Smoking, by Race/Ethnicity—U.S., 2004

0% 10% 20% 30% 40% 50%

11.3% Asian

33.4% American Indian/Alaska Native

20.2% Black, non-Hispanic

22.2% White, non-Hispanic

15.0% Hispanic

Centers for Disease Control and Prevention. (2005). MMWR 54:1121–1124.

Tobacco Tipping Point?

• California 14% adult smoking prevalence• Northern California Kaiser Permanente

down to 9%• Physicians around 2%• Proliferation of smoke-free areas• Increasing stigmatization of smoking

1.41.8

2.3

5:066:07

7:04

36%45%

58%

Hours of TV Viewed Daily1960-1992

Millions of Person-Miles in

Automobiles, 1970-1990

Percent of Workforce in Sedentary

Occupations, 1950-1996

1970 1990

800 k-calories/day decrease in 20 years

Emergence of an Inactive Society

Year

70.269.190.6200474.560.272.81994

Hyperlipidemia

55.833.343.8200472.459.652.31994

Smoking

28.040.253.1200426.929.635.91994

Diabetes

81.181.084.4200461.965.378.71994

Hypertension

38.642.934.4200421.829.26.91994

Obesity

CaucasianHispanicFilipinoRisk Factors1994 - 2004

RISK FACTORS FOR HEART ATTACK AND STROKE – FILIPINOS

Colman Ryan, MD

Between 1994 and 2008

18.82004

72.81994

52.31994

35.91994

78.71994

89.12008

90.62004Hyperlipidemia

53.12008

43.82004Smoking

50.02008

53.12004Diabetes

95.32008

84.42004Hypertension

31.32008

6.91994

Obesity

FilipinoYearRisk Factors

Coronary Artery Disease

Photos courtesy of Boehringer Ingleheim International GmbH, by Lennart Nilsson.

The Beginning of Atherosclerosis


Atherosclerotic Plaque


Plaque Rupture


Platelet Activation


Myocardial Infarction


National Geographic, August 2004

Changing Portion Sizes

National Geographic, August 2004

2004

20042004

2004

2004

Visceral Adiposity

Fat Depots:Subcutaneous: 60-70%Intra-abdominal: 15-25%• Visceral (or intraperitoneal)

• Retroperitoneal (5%)Intramuscular: 5-10%

Visceral Fat

Déspres, Quebec

Growing Percentage of People Over 60 Years of Age (2000-2025)

Americans Complacent About CVD

CVD Risk FactorsHypertension*Cigarette smokingObesity* (BMI >30 kg/m2)Physical inactivityDyslipidemia*Diabetes mellitus*Microalbuminuria or estimated GFR <60 ml/minAge (older than 55 for men, 65 for women)Family history of premature CVD (men under age 55 or women under age 65)

*Components of the metabolic syndrome.

I love this Doctor

Q: Doctor, I've heard that cardiovascular exercise can prolong life. Is this true?

A: Your heart is only good for so many beats, and that's it... don't waste them on exercise. Everything wears out eventually. Speeding up your heart will not make you live longer; that's like saying you can extend the life of your car by driving it faster. Want to live longer? Take a nap.

Q: Should I cut down on meat and eat more fruits and vegetables?

A: You must grasp logistical efficiencies. What does a cow eat? Hay and corn. And what are these? Vegetables. So a steak is nothing more than an efficient mechanism of delivering vegetables to your system. Need grain? Eat chicken. Beef is also a good source of field grass (green leafy vegetable). And a pork chop can give you 100% of your recommended daily allowance of vegetable products.

Q: Aren't fried foods bad for you?

A: YOU'RE NOT LISTENING!!! ..... Foods are fried these days in vegetable oil. In fact, they're permeated in it. How could getting more vegetables be bad for you?

Q: Will sit-ups help prevent me from getting a little soft around the middle?

A: Definitely not! When you exercise a muscle, it gets bigger. You should only be doing sit-ups if you want a bigger stomach.

Q: Is chocolate bad for me?

A: Are you crazy? HELLO Cocoa beans ! Another vegetable!!! It's the best feel-good food around!

Q: Is swimming good for your figure?

A: If swimming is good for your figure, explain whales to me.

Q: Is getting in-shape important for my lifestyle?

A: Hey! 'Round' is a shape!

Well, I hope this has cleared up any misconceptions you may have had about food and diets.

And remember:'Life should NOT be a journey to the grave with the intention of arriving safely in an attractive and well preserved body, but rather to skid in sideways -Chardonnay in one hand - chocolate in the other - body thoroughly used up, totally worn out and screaming 'WOO HOO, What a Ride'

AND.....

risk factors for stroke and heart attack[2]...cvd risk factors hypertension* cigarette smoking...

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