Heart Disease is the major health challenge of the 21st century. Unless something is done, by 2020, 36 out of every 100 people will die of heart disease and stroke. The rate of increase will be greatest in low and middle income countries, those countries that can least afford it.

“Heart disease and stroke are not inevitable. They are largely preventable. Preventive measures will reduce the incidence of death and disability.” Prof. Mario Maranhão, Past-President, World Heart Federation

Source : World Health Report 2002

WORLD HEART FEDERATION

“Superior Doctors Prevent the Disease. Mediocre Doctors Treat the Disease Before Evident. Inferior Doctors Treat the Full Blown Disease.”

-Huang Dee: Nai - Ching (2600 B.C. 1st Chinese Medical Text)

Population 6,000,000,000

Total deaths per year 54,000,000 (0.9%)

Cardiovascular death 17,000,000 (31%)

44% coronary heart disease

31% stroke78% in low income

countries

AIDS 3,000,000Tuberculosis 1,000,000Malaria 1,000,000 (mostly in Africa)

Global causes of death

One out of every 3 deaths

17 million deaths worldwide 1999 estimated to reach 25 million in 2020

Six times the current number of deaths from HIV/Aids

80% of deaths are in low/middle income countries

Sources: WHO World Health Report 2000, CVD infobase

WORLDWIDE CVD FACTS

Atherothrombosis = major cause of death in the western world

ATHEROSCLEROSIS: A SYSTEMIC DISEASE

CADCAD21%21%

CVACVA9%9%

PADPAD8%8%

8%8%

5%5%

9%9% 3%3%

ATHEROSCLEROSIS

Chronology of Atherosclerotic Artery Disease

Atherosclerosis Plaque SCA Prevention Vulnerable Secondary

IschemicArtery Disease

CoronaryCerebral Peripheral

Antman EM modf. Libby P. Circulation 2001;104:365

Cardiovascular Risk Factors

Protecting your Heart

Maternal and children undernutrition HIgh Risk Sex High Blood Pressure Tobacco Smoking Alcohol Abuse Unsafe Water and lack of basic sanitary and hygiene High Cholesterol Pollution of the air at home Iron defficiency Obesity

Causes of 40% of the 56 millions of deathIn the world.

WHO – 10 MORE IMPORTANT RISKS 2002

• Smoking

• Hypertension (BP ≥ 140/90 mmHg)

• Low HDL-C ( < 40 mg/dL)

• Early Family History atherosclerosis (1st grade relatives < 55 years for men and <65 for women

• Age (≥ 45 years males/ ≥55 years females)

• AF** + CAD/ relatives 1st grade• (<55 anos males/<65 anos females)

• Diabetes melitus (glucose > 126 mg/dL)

Caracterization of the Independent Risk Factors for atherosclerosis

INDEPENDENT

Hypertension

Tobacco Smoking

Total Cholesterol & High LDL-C

HDL-CDiabetes Melitus

Aging

Menopause

CVD Risk Factors for Atherosclerosis

CONDITIONAL

Triglycerides

LDL type B

Homocystein

Lp (a)*

Fibrinogen

Inflammatory Markers

FAVOURING

Obesity

Abdominal Obesidade

Physical Inactivity

Early Family History

Ethnic

Social & Psychologic Factors

• Obesity• Metabolic Syndrome• Physical Inactivity• High cholesterol and saturated fat diet

• New Risk Factors

• Inflamatory factors (RCP + de high sensibility)• Homocystein high levels• Lp (a)++• Prothrombotic Factors• Glucose intolerance• Sub-clinical Aterosclerose (coronary Ca+,

intimal thickness)

Potentiation of Risk by the Following Factors

PREVALENCE OF RISK FACTORS

OVERWEIGHT/ OBESITY-MCI ≥ 25Kg/m² 41,0% SMOKING 32,9% DIABETES 7,6%HYPERTENSION -BRASIL IBGE 15,0% HIGH CHOLESTEROL ≥ 240mg 16,0%

World-wide sales/consumption increasing

2/3 young men in China smoke

40% men in India use Tobacco products

~50% women under age 30 in East Germany smoke (doubled in 5 years)

Source: Sir Richard Peto / Bundeszentrale für gesundheitliche Aufklärung

LIFESTYLE TRENDS & CVD TOBACCOLIFESTYLE TRENDS & CVD TOBACCO

Sources: WHO World Health Report 2000, CVD infobase

600 million with Hypertension at risk of heart attack, stroke, heart failure

180 million high income countries

420 million420 million from low/middle income countries

LIFESTYLE TRENDS & CVD HYPERTENSIONLIFESTYLE TRENDS & CVD HYPERTENSION

ARTERIAL BLOOD PRESSURE CLASSIFICATION IN ADULTS

ClassClass

• NormalNormal

• Pre-HipertensionPre-Hipertension

• HiperHiperttension 1 stage ension 1 stage

• HiperHiperttension 2 stageension 2 stage

SP* mmHg

<120

120-139

140-159

≥160

DP

E<80

or 80-89

or 90-99

or ≥100

GOAL

General Population <140/90

High Risk Patients for CAD & Diabetes <130/85

HYPERTENSION

150 Million Diabetics (90% type II)

Incidence projected to double in 25 years

Projected increase highest in India and China

Increased incidence for younger age groups

Source : Diabetes and Cardiovascular Disease, IDF

LIFESTYLE TRENDS & CVD DIABETES

LIFESTYLE TRENDS & CVD DIABETES

DIABETES MELLITUS Diagnosis

Categories fasting 2H After 75g Casual of glucose

Fasting High

Glycemic Levels >110 and <126 <140

Low Glucose

Tolerance <126 and ≥ 140 and <200

Diabetes

Mellitus ≥ 126 or 200 or ≥200

(classic symptoms)

Objectives in the treatment of Diabetes Mellitus

Fasting Blood Glucose (mg/dL)

Post-Prandrial Glucose

(2h)(mg/Dl)

HbA1c(%)

BMI

Optimal

<110*

<140

<6,0*

<25

Accept

<126

<160

<1,0 above

<27

Normal Less than 25

Overweight 25 to 30

Obesity 30 to 40

Morbid Obesity More than 40

BODY MASS INDEX (BMI)

300 Million obese adults globally

Obesity in high income countries

doubled in UK 1980-1999:8-21% women 6-19% men

US 30% overweight adults: 15% obese F>M

Also trend in low/middle income countriesKuwait 44% women 32% menBrazil 12% women 7% menPakistan (urban) 20% women 10% men

Source: British Medical Journal, Report of WHO Nutrition 2000

LIFESTYLE TRENDS & CVD OBESITY

LIFESTYLE TRENDS & CVD OBESITY

Metabolic Syndrome: Risk FactorsMetabolic Syndrome: Risk FactorsMetabolic Syndrome: Risk FactorsMetabolic Syndrome: Risk Factors

Abdominal Obesity*Abdominal Obesity*(abdominal circunference)**(abdominal circunference)**Abdominal Obesity*Abdominal Obesity*(abdominal circunference)**(abdominal circunference)**

RiskRisk FactorsFactors RiskRisk FactorsFactors Accepted LevelsAccepted Levels Accepted LevelsAccepted Levels

Man > 102 cmMan > 102 cmWoman > 88 cmWoman > 88 cmTriglycerides Triglycerides >> 150 mg/dL 150 mg/dL HDL-CholesterolHDL-CholesterolMan < 40 mg/dLMan < 40 mg/dLWoman < 50 mg/dLWoman < 50 mg/dL Blood Pressure Blood Pressure >> 130/ 130/>>85mmHg85mmHg Fasting Glucose Fasting Glucose >> 110 mg/dL 110 mg/dL

Man > 102 cmMan > 102 cmWoman > 88 cmWoman > 88 cmTriglycerides Triglycerides >> 150 mg/dL 150 mg/dL HDL-CholesterolHDL-CholesterolMan < 40 mg/dLMan < 40 mg/dLWoman < 50 mg/dLWoman < 50 mg/dL Blood Pressure Blood Pressure >> 130/ 130/>>85mmHg85mmHg Fasting Glucose Fasting Glucose >> 110 mg/dL 110 mg/dL

LIFESTYLE TRENDS & CVD DIABETES

LIFESTYLE TRENDS & CVD DIABETES

150 Million Diabetics (90% type II)

Incidence projected to double in 25 years

Projected increase highest in India and China

Increased incidence for younger age groups

Source : Diabetes and Cardiovascular Disease, IDF

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•

44 55 66 77 88

11

44

00

22

33

55

Pooling Project Framingham Study Israel prospective

CAD Risk

Ratio

CAD Risk

Ratio

Relation between plasma cholesterol & Relation between plasma cholesterol & Relative risk for CADRelative risk for CAD

Plasma Cholesterol (mmol/L))Plasma Cholesterol (mmol/L))

• • • •

• •

• •

3.93.9 5.25.2 6.56.5 7.87.82.62.6

1.01.0

2.02.0

3.03.0

4.04.0

0.70.71.01.0

2.02.0

4.04.0

CHDRiskRatio

CHDRiskRatio

Serum Cholesterol (mmol/L) Serum Cholesterol (mmol/L)

CAD and Age: MRFIT StudyCAD and Age: MRFIT Study

361. 662 361. 662 Men (Ages Men (Ages

35-57)35-57)

Relation between LDL-c & Relation between LDL-c & CAD RiskCAD Risk

Relation between LDL-c & Relation between LDL-c & CAD RiskCAD Risk

LDL - cholesterolLDL - cholesterol

<100 Optimal100-129 Near Optimal130-159 Mild High 160-189 High> 190 Very High

<100 Optimal100-129 Near Optimal130-159 Mild High 160-189 High> 190 Very High

Total Cholesterol Total Cholesterol

<200 Desirable200-239 Slight High> 240 High HDL-cholesterolHDL-cholesterol

<40 Low>60 High<40 Low>60 High

Age Effect on Serum Age Effect on Serum Lipoprotein LevelsLipoprotein Levels

Age Effect on Serum Age Effect on Serum Lipoprotein LevelsLipoprotein Levels

mmo/l mg/dl 6.2 240

mmo/l mg/dl 6.2 240

CholesterolCholesterol

3.6 140 3.6 140

1.0 39 1.0 39

0 10 20 30 40 50 6070 80

Total Total

LDLLDL

HDLHDL

Men Men WomenWomen

AgeAge

Effects of Age on TriglycerídeosEffects of Age on TriglycerídeosEffects of Age on TriglycerídeosEffects of Age on Triglycerídeos

2.0 177

1.8 159

1.6 142

1.4 124

1.2 106

1.0 89

25-29

30-3435-3

940-4

445-4

950-5

455-5

9

mmo/l mg/dl

mmo/l mg/dl

Meanplasma

Triglyceride(mmol/l)

Meanplasma

Triglyceride(mmol/l)

AgeAge

MenMen

WomenWomen

CAD in Diabetetic Patients: Mean Annual rateCAD in Diabetetic Patients: Mean Annual rateFramingham StudyFramingham Study

CAD in Diabetetic Patients: Mean Annual rateCAD in Diabetetic Patients: Mean Annual rateFramingham StudyFramingham Study

Age group (years)Age group (years)

40 - 4940 - 49 50 - 5950 - 59 60 - 6960 - 69 70 - 7970 - 79

1212

2424

3636

4848

00

Rate per 1000

Rate per 1000

MenMen

Diabetic Non Diabetic

001212

24243636

48486060

Age group (years)Age group (years)

40 - 4940 - 49 50 - 5950 - 59 60 - 6960 - 69 70 - 7970 - 79

Rate per 1000

Rate per 1000

WomenWomen

Diabetic Non Diabetic

CAD in Diabetic Patients : Mean Annual RateCAD in Diabetic Patients : Mean Annual Rate Framingham StudyFramingham Study

Secondary DyslipidemiaSecondary DyslipidemiaSecondary DyslipidemiaSecondary Dyslipidemia

CAUSESCAUSES• Diabetes MellitusDiabetes Mellitus• HypothireoidismoHypothireoidismo• ObesityObesity• Nephrotic SyndromeNephrotic Syndrome• Chronic Renal FailureChronic Renal Failure• DrugsDrugs• AlcoholAlcohol• Hepatic DiseaseHepatic Disease• Obstructive Biliary DiseasesObstructive Biliary Diseases• Collagen DiseasesCollagen Diseases

HIGH

• Absolute Risk > 20% in 10 years MEAN

• Absolute Risk > 10 a 20% in 10 years LOW

• Absolute Risk <10% in 10 years

Cardiovascular Risks for CAD

• Coronary Artery Disease (CAD)

• Cerebrovascular Disease

• Synptomatic Carotid Atheroma, CVA*, TiA+,

• Cerebrovascular Insufficiency

• Peripheral Vascular Insufficiency (PVI)

CAD CLINICALLY MANIFESTED:PREVENTION OF HIGH RISK

• Diabetes mellitus (DM)

• Individuals in primary prevention with absolute risk of events > 20% 10 years ( generally with two or more CV risk factors other than cholesterol) Refer to Framinghan Risk Tables

Individuals without Atherosclerosis Diseases

Evidence

HIGH RISK PREVENTION

• Absolute Risk for events > 10%, but 20% in 10 years

• Individuals with 2RF** (except DM) beyond cholesterol

(LDL-c > 160 mg/dL) • Refer the Framinghan score for risk

Use the absolute score of risk factors (Framinghan) for events in 10 years

MEAN RISK

• Absolute Risk of events < 10%,

• Individuals with 1RF** (except for DM) beyond cholesterol

(LDL-c > 160 mg/dL) or just high LDL-c

It’s not necessary to refer to the

scores of risk of Framingham.

LOW RISK

Proposed Goals for Lipids Levels according risk factors for CAD

LDL-c HDL-c TG HIGH RISK

• Pacients with CAD,PVI* or • symptomatic carotid atherosclerosis <100 >40 <150

• Pacients with Diabetes <100 >45 <150• Risk for CAD in 10 years ≥20% <100 >40 <150 MEAN RISK• Risk for CAD in 10 years >10% e <20% <130 >40 <150

• LOW RISK

Risk for CAD in 10 years <10% <130* >40 <150

LIFE STYLE CHANGES

DIET

EXERCISE

WEIGHT

SMOKING

HEALTHY DIAT AND LIFE STYLE CHANGESHEALTHY DIAT AND LIFE STYLE CHANGESHEALTHY DIAT AND LIFE STYLE CHANGESHEALTHY DIAT AND LIFE STYLE CHANGES

Saturated Fats < 7% total cal.Poliunsaturated Fats up to 10% total cal.Monounsaturated Fats up to 20% total cal.Total Fat 25 - 30% of the total cal.Complex Carbohydrates 50 - 60% of the total cal.Fibers 20 - 30g/dailyProteins Approximately 15% of the total cal.Cholesterol < 200 mg/dayPhytosterols 3-4g/dayFibers 20 - 30g/day (6g soluble)Total Calories Balance between energetic gain & losses daily to keep the ideal weight.

Saturated Fats < 7% total cal.Poliunsaturated Fats up to 10% total cal.Monounsaturated Fats up to 20% total cal.Total Fat 25 - 30% of the total cal.Complex Carbohydrates 50 - 60% of the total cal.Fibers 20 - 30g/dailyProteins Approximately 15% of the total cal.Cholesterol < 200 mg/dayPhytosterols 3-4g/dayFibers 20 - 30g/day (6g soluble)Total Calories Balance between energetic gain & losses daily to keep the ideal weight.

NutrientsNutrients NutrientsNutrients Recommended IntakeRecommended Intake Recommended IntakeRecommended Intake

Relation Between CHD Events andRelation Between CHD Events andLDL Cholesterol in Recent Statin TrialsLDL Cholesterol in Recent Statin Trials

% W

ith

CH

D E

ven

t%

Wit

h C

HD

Even

t

00

55

1010

1515

2020

2525

3030

9090 110110 130130 150150 170170 190190 210210

Mean LDL-C Level at Follow-up (mg/dL)Mean LDL-C Level at Follow-up (mg/dL)

4S-PI4S-PI

4S-Rx4S-Rx

LIPID-RxLIPID-Rx

CARE-RxCARE-Rx

LIPID-PILIPID-PI

CARE-PICARE-PI

AFCAPS/TexCAPS-RxAFCAPS/TexCAPS-Rx

AFCAPS/TexCAPS-PIAFCAPS/TexCAPS-PI

WOSCOPS-RxWOSCOPS-Rx

WOSCOPS-PIWOSCOPS-PI

1° Prevention1° Prevention

2° Prevention2° Prevention

LIFESTYLE TRENDS & CVD WOMEN

LIFESTYLE TRENDS & CVD WOMEN

Women unaware of their CVD risk

CVD affects women around the globe

CVD deaths 8 times higher than breast/ovarian cancers

India, China and Latin America account for 48% of deaths.

ADDITIONAL RISK FACTORS

ADDITIONAL RISK FACTORS

Mental stress, anxiety and depression,as well as, social factors.

Depression is present up to 45% of cases of acute myocardial infarction(AMI).

If unknown or untreated, depression favors a second MI (2½-4 times more), increasing the possibility of death up to 5 times more.

 

DEPRESSION AS A RISK FACTOR FOR CARDIOVASCULAR DISEASES

HIPPISLEY-COX, J., FIELDING, K., PRINGLE, M. Depression as a risk factor for ischaemic heart

disease in men : population based-control study.

BRITISH MEDICAL JOURNAL, 1998; 316 : 1714-1719

 

Depression and CardioVascular Diseases

COFFEE HEART STUDY Depression is an independent risk factor for

cardiovascular diseases (DCV)

Analysis of “U.S. National Health and Nutrition Examination Survey (NHANES)” showed that patients with depression has 2,5 to 4 times greater of risk of coronary artery diseases like myocardial infarction and 5 times greater risk of sudden death.

Depression is a bad marker for cardiovascular prognosis and survival.

May coffee prevent depression and Myocardial Infarction? Report from WHO/WHF in 2004.

Coffee x CAD ?

?