Cardiovascular Epidemiology: Definitions Historical Perspectives and Assessing Risk of CVD Recent...
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Cardiovascular Cardiovascular Epidemiology: Epidemiology: Definitions Definitions Historical Perspectives and Historical Perspectives and Assessing Risk of CVD Assessing Risk of CVD Recent trends and Recent trends and population differences in population differences in CHD and CHD risk factors CHD and CHD risk factors
Cardiovascular Epidemiology: Definitions Historical Perspectives and Assessing Risk of CVD Recent trends and population differences in CHD and CHD risk
Cardiovascular Epidemiology: Definitions Historical
Perspectives and Assessing Risk of CVD Recent trends and population
differences in CHD and CHD risk factors
Slide 2
Deaths in Thousands A Total CVD B Cancer C Accidents D Chronic
Lower Respiratory Diseases E Diabetes Mellitus F Alzheimers Disease
Leading causes of death for all males and females (United States:
2004). Source: NCHS and NHLBI.
Slide 3
Percentage breakdown of deaths from cardiovascular diseases
(United States:2004) Source: NCHS and NHLBI. Coronary Heart Disease
Heart Failure Diseases of the Arteries Defects Rheumatic Fever/
Rheumatic Heart Disease Stroke High Blood Pressure Congenital
Cardiovascular Other
Slide 4
Cardiovascular disease deaths vs. cancer deaths by age (United
States: 2004). Source: NCHS and NHLBI.
Slide 5
Development of Atherosclerotic Plaques Normal Fatty streak Foam
cells Lipid-rich plaque Lipid core Fibrous cap Thrombus Ross R.
Nature. 1993;362:801-809.
Slide 6
Intraluminal thrombus Growth of thrombus Intraplaque
thrombusLipid pool Blood Flow Atherosclerotic Plaque Rupture and
Thrombus Formation Adapted from Weissberg PL. Eur Heart J
Supplements 1999:1:T1318
Slide 7
PDAY: Percentage of Right Coronary Artery Intimal Surface
Affected With Early Atherosclerosis PDAY= PDAY= Pathobiological
Determinants of Atherosclerosis in Youth. Strong JP, et al. JAMA.
1999;281:727-735. Fatty streaks Raised lesions White
15-1920-2425-2930-34 0 10 20 30 Women 0 10 20 30
15-1920-2425-2930-34 Black Age (y) 0 10 20 30 White
15-1920-2425-2930-34 Men Black 15-1920-2425-2930-34 0 10 20 30
Intimal surface (%)
Slide 8
(Adapted from Glagov et al.) Coronary Remodeling
NormalvesselMinimalCAD Progression Compensatory expansion maintains
constant lumen Expansion overcome: lumen narrows
SevereCADModerateCAD Glagov et al, N Engl J Med, 1987.
Slide 9
Most Myocardial Infarctions Are Caused by Low-Grade Stenoses
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.) Falk E et al, Circulation, 1995.
Slide 10
Libby P. Circulation. 1995;91:2844-2850. Vulnerable Plaque Thin
fibrous cap Inflammatory cell infiltrates: proteolytic activity
Lipid-rich plaque Lumen Lipid Core Fibrous Cap Thick fibrous cap
Smooth muscle cells: more extracellular matrix Lipid-poor plaque
Stable Plaque Lumen Lipid Core Fibrous Cap Vulnerable Versus Stable
Atherosclerotic Plaques
Slide 11
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)
Slide 12
Eccentric, lipid-rich Fragile fibrous cap Prior luminal
obstruction < 50% Visible rupture and thrombus Constantinides P.
Am J Cardiol. 1990;66:37G-40G. Features of a Ruptured
Atherosclerotic Plaque
Slide 13
Clinical Manifestations of Atherosclerosis Coronary heart
diseaseCoronary heart disease Stable angina, acute myocardial
infarction, sudden death, unstable angina Cerebrovascular
diseaseCerebrovascular disease Stroke, TIAs Peripheral arterial
diseasePeripheral arterial disease Intermittent claudication,
increased risk of death from heart attack and stroke American Heart
Association, 2000.
Slide 14
Definitions CARDIOVASCULAR DISEASE or CVD includes CORONARY
ARTERY DISEASE and other cardiac conditions (congenital,
arrhythmias, and congestive heart failure)CARDIOVASCULAR DISEASE or
CVD includes CORONARY ARTERY DISEASE and other cardiac conditions
(congenital, arrhythmias, and congestive heart failure) 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,
revascularization, and myocardial infarctionCORONARY 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, revascularization,
and myocardial infarction
Slide 15
Definitions (cont.) REVASCULARIZATION includes coronary artery
bypass graft (CABG), percutaneous transluminal coronary angioplasty
(PTCA), stent, and atherectomyREVASCULARIZATION includes coronary
artery bypass graft (CABG), percutaneous transluminal coronary
angioplasty (PTCA), stent, and atherectomy CEREBROVASCULAR DISEASE
includes stroke (ischemic or hemorrhagic) and transient ischemic
attack (TIA)CEREBROVASCULAR DISEASE includes stroke (ischemic or
hemorrhagic) and transient ischemic attack (TIA) PERIPHERAL
VASCULAR DISEASE includes carotid artery disease and intermittent
claudicationPERIPHERAL VASCULAR DISEASE includes carotid artery
disease and intermittent claudication SURROGATE MEASURES include:
carotid intimal medial thickness (IMT), coronary calcium,
angiographic stenosis, brachial ultrasound flow mediated dilatation
(FMD)SURROGATE MEASURES include: carotid intimal medial thickness
(IMT), coronary calcium, angiographic stenosis, brachial ultrasound
flow mediated dilatation (FMD)
Slide 16
Prevalence of cardiovascular diseases in adults age 20 and
older by age and sex (NHANES: 1999-2004). Source: NCHS and NHLBI.
These data include coronary heart disease, heart failure, stroke
and hypertension.
Slide 17
Prevalence of coronary heart disease by age and sex (NHANES
:1999-2004). Source: NCHS and NHLBI.
Slide 18
Annual Number of Americans Having Diagnosed Heart Attack by Age
and Sex ARIC: 1987-2000 Source: Extrapolated from rates in the
NHLBIs ARIC surveillance study, 1987-2000. These data dont include
silent MIs.
Slide 19
Annual Rate of First Heart Attacks by Age, Sex and Race ARIC:
1987-2000 Source: NHLBIs ARIC surveillance study, 1987-2000.
Slide 20
Prevalence of stroke by age and sex (NHANES: 1999-2004).
Source: NCHS and NHLBI.
Slide 21
Prevalence of heart failure by age and sex (NHANES: 1999-2004).
Source: NCHS and NHLBI.
Slide 22
Note: Hospital discharges include people discharged alive, dead
and status unknown.. Hospital discharges for heart failure by sex
(United States: 1979-2004). Source: NHDS, NCHS and NHLBI.
Slide 23
Cardiovascular disease mortality trends for males and females
United States: 1979-2004). Source: NCHS and NHLBI. Cardiovascular
disease mortality trends for males and females (United States:
1979-2004). Source: NCHS and NHLBI. 0
Slide 24
Source: NHLBI 2002 Chart Book on Cardiovascular, Lung, and
Blood Diseases
Slide 25
Slide 26
Lifetime Risk of Coronary Heart Disease in the Framingham Study
Men Women At age 40 years:48.6%31.7% At age 70 years:34.9%24.2%
Lloyd-Jones et al. Lancet 1999; 353:89-92
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Slide 27
First Coronary Events: Framingham Study Percent as Specified
Event MyocardialAngina Sudden InfarctionPectoris Death AgeMen Women
Men Women Men Women 35-64 43%28% 41% 59% 9% 4% 65-8455%44% 28% 41%
11% 7.4% Framingham Study 44 year follow-up.
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Slide 28
Estimated 10-Year CHD Risk in 55-Year-Old Adults According to
Levels of Various Risk Factors Framingham Heart Study A B C D A B C
D Blood Pressure (mm Hg)120/80140/90140/90140/90 Total Cholesterol
(mg/dL) 200 240 240 240 HDL Cholesterol (mg/dL) 50 50 40 40
Diabetes No No Yes Yes Cigarettes No No No Yes mm Hg = millimeters
of mercury mg/dL = milligrams per deciliter of blood
Source:Circulation 1998;97:1837-1847.
Slide 29
Estimated 10-Year Stroke Risk in 55- Year-Old Adults According
to Levels of Various Risk Factors Framingham Heart Study ABCDEF
Systolic BP*95-105130-148130-148130-148130-148130-148
DiabetesNoNoYesYesYesYes CigarettesNoNoNoYesYesYes Prior Atrial
Fib.NoNoNoNoYes Yes Prior CVDNoNoNoNoNoYes Source: Stroke
1991;22:312-318. *BP in millimeters of mercury (mmHg)
Slide 30
ABCDEF Systolic BP*95-105130-148130-148130-148130-148130-148
DiabetesNoNoYesYesYesYes CigarettesNoNoNoYesYesYes Prior Atrial
Fib.NoNoNoNoYes Yes Prior CVDNoNoNoNoNoYes Estimated 10-year stroke
risk in 55-year-old adults according to levels of various risk
factors (FHS). Source: Wolf et al., Stroke.1991;22:312-318. *BP in
millimeters of mercury (mmHg)