1

RISK FACTORS OF CARDIOVASCULAR DISEASES

DR. Vaibhav Gupta

MPH 2nd year

Dept. of community medicine

JSSMC

07/09/2013

MODERATOR: DR. N.C ASHOK

2

3

Introduction

CHD (IHD) is a group of closely related syndromes resulting

from myocardial ischemia – an imbalance between the

supply or perfusion and demand of heart for oxygenated

blood.

Definition: “ Impairment of heart function due to inadequate

blood flow to the heart compared to its needs, caused by

obstructive change in the coronary circulation to the heart”.

• 25- 30% deaths in most industrialized countries.

4

Pál Kertai:“Cardiovascular disease has the same meaning

for health care today as the epidemics of centuries had for

medicine in earlier times: 50% of the population in

developed countries die of cardiovascular disease”

British Heart Foundation:“Someone has a heart attack

every two minutes”

5

Problem statement

World:

• In today's world , most deaths are attributable to non

communicable diseases 35million and just over half of these

17 million are as a result of CVD.

• more then one third of these deaths occur in middle-aged

adults.

• Developed countries heart disease and stroke are the second

leading cause of death for adults men & women .

6

Cont.......

Fact sheet on CVDs• An estimated 17.3 million people died from CVDs in

2008.

• Over 80% of CVD deaths take place in low- and

middle-income countries.

• By 2030 more than 23 million people will die

annually from CVDs

7

Cont..

India:

29.8million patients with cardiovascular disease

2003.An estimated 1.5million people die of CVD

every year.

The burden of common CVD are, about 0.93 million

stroke cases every year.

8

International variations CHD is now considered as our “Modern Epidemic”. Not an

unavoidable consequence of aging.

Epidemics of CHD began at different times in different

countries. Developed countries were the first to be affected

At present, CHD is decreasing in many developed countries, but

is increasing in developing and transitional countries, partly as a

result of increased longevity, urbanization and lifestyle changes

Highest mortality is found in European countries followed by

SEAR countries.

9

Mortality and morbidity due to CHD, global estimates for 2004

10

CHD IN INDIA

There is a steep increase in prevalence of IHD in urban areas in India

(considerable increase in the last decade).

Although there is an increased prevalence in the rural areas, the

lifestyle changes have affected people more in urban areas than

that in rural areas.

Expected to be the single most important cause of death in India by

2015.

Prevalence in URBAN -6.4%/1000, RURAL-2.5%/1000

Death rate in URBAN-0.8%/1000, RURAL-0.4% /1000

CHD in the United States

• CHD is the single largest killer of men and women

• 13.9 million have history of MI and angina

• Each year 1.1 million people have MI

MI- 3,70,000 die & 2,50,000 die within 1 hr

• By age 60, every 5th man and 17th woman develops CHD

• 1998 estimated direct and indirect costs of heart disease are $95.6 billion

• 53.3 million adults have elevated LDL-C and warrant intervention (1994 NHANES data)

22.3 million qualify for drug therapy, 5.5 million receive therapy

11

12

Cont...

• AHA. 1998 Heart and Stroke Statistical Update;

1997.

• National Center for Health Statistics.

• National Health and Nutrition Examination Survey

(III); 1994. (Data collected 1991-1994.)

13

World Health Day Theme

• 27 March 2013 -- The theme for this year's, 7 April, is

hypertension. Also known as high or raised blood pressure,

hypertension increases the risk of heart attacks, strokes and

kidney failure. Uncontrolled hypertension can also cause

blindness, irregularities of the heartbeat and heart failure.

However, high blood pressure is preventable and treatable.

Early detection is key: all adults should know their blood

pressure.

14

Gaps In Natural History

• There are many gaps in our Knowledge about the the

natural history of chronic diseases. These gaps cause

difficulties in aetiological investigation and research.

Theses are-

1. Absence of a know agent: some of chronic disease the

cause is known silica in silicosis. For many chronic

disease the causative agent is not known. The absence of

known agent makes both diagnosis & specific prevention

difficult.

15

cont,...

2. Multifactorial causation: Most chronic diseases are

the result of multiple causes –one –to- one cause –

effect relationship.

The concept of disease “agent”& stress multiplicity

of interactions between host & environment.

16

Cont..

3. Long latent period : chronic diseases is the long

latent period the first exposure to “suspected cause”

and the eventual development of disease (cervical

cancer)

4 Indefinite onset: Most chronic disease are slow in

onset and development and may be difficult to

establish.(diabetes and hypertension)

17

Non Communicable Disease Risks Factors

• Six key of risks factors

1. Cigarette use and other form of smoking.

2. Alcohol abuse

3. Failure or inability to obtain preventive health services.(hypertension control, cancer detection, management of diabetes)

4. Life- style changes( dietary patterns, physical activity)

5. Environmental risks factors ( occupation hazards, air and water pollution and possession of destructive weapons in case of injuries)

6. Stress factors

18

Cardiovascular disease (CVD)

• Cardio- = The Heart

• Vascular= Blood Vessels

• Cardiovascular diseases = disease of The Heart + Blood

vessels

19

Cardiovascular Disease

Cardiovascular diseases (CVD) comprise of group of disease of

the heart and the vascular system.

The major conditions are:

Ischemic heart disease

Hypertension

Cerebrovascular disease (stroke)

Congenital heart disease

Rheumatic heart disease

20

MEASURING THE BURDEN OF THE DISEASE

1. Proportional mortality ratio

2. Loss of life expectancy

3. CHD incidence rate

4. Age specific death rates

5. Prevalence rate

6. Case Fatality rates

7. Measuring the risk factors levels

8. Medical care

21

Major Risks Factors of CVD

• Tobacco use

• Inappropriate diet

• Physical inactivity

• 75- 85% new cases of coronary health disease

22

CHD can manifest itself in any of the following ways

Angina Pectoris

Myocardial Infarction \ Heart Attack

Irregularities of the Heart

Cardiac failure

Sudden Death

23

Age specific Prevalence RatesAGE GROUP

Urban (PR/1000) Rural(PR/1000)

M F M F

20-24 8 6 17 10

25-29 19 26 13 15

30-34 17 22 12 10

35-39 43 48 18 15

40-44 47 65 17 23

45-49 83 105 20 38

50-54 93 112 30 50

55-59 162 152 26 50

60+ 174 175 70 67

24

CHD RISK FACTORES

25

Modifiable

o Cigarette smokingoHigh blood pressureo Elevated serum

cholesteroloDiabetesoObesityo Sedentary Habitso Stress

Non Modifiable

oAgeo Sexo Family historyoGenetic Factorso Personality

26

Non Modifiable 1.Age

• Aging strongly associated with atherosclerosis due to:

– Cumulative exposure to risk factors

– Degeneration of blood vessels with age

• Aging becomes a significant risk factor for:

– Men at age 45 or older,

– Women at age 55 or older as they reach menopause

27

2.Gender

• Gender difference in age of coronary heart disease

onset has been attributed to:

– A protective effect of estrogen in women

– Men also tend to have other possible risk factors:

• Higher homocysteine levels

• Higher risk of iron overload

• Ultimately, coronary heart disease kills as many

women as men

28

3.Family History

• Family history of early coronary heart disease in one’s

immediate family members is an independent risk factor,

independent of other risk factors

29

Modifiable

1.SMOKING

• Mechanism by which cigarette smoking

contribute to CHD are Carbon monoxide induced

atherogenesis

Nicotinic stimulation of adrenergic drive

Lipid metabolism with fall in protective high

density lipoproteins

30

31

2.Blood Pressure

• For people over 50 years of age, a high systolic blood

pressure is more predictive of coronary heart disease risk

than diastolic blood pressure

• High blood pressure is ≥140/ ≥90 mm Hg

32

2.Diabetes

• High blood glucose can attach (glycate) to proteins

forming glycoprotein

– These proteins can damage blood vessels and worsen

atherosclerosis

• Other effects of diabetes promote blood clot formation

33

3.Obesity

• Overweight = BMI 25.0-29.9

• Obese = BMI ≥ 30

• Recommended BMI = 18.5 – 24.9

34

Others Risks Factors

1. Genetic Factors

2. Physical activity

3. Hormones

4. Type A personality

5. Alcohol

6. Oral contraceptives

7. Miscellaneous

35

Cardiovascular Prevention

Primordial: Social, legal and other (often

nonmedical) activities which may lead to a

lowering of risk factors (e.g., socioeconomic

development, smoke-free restaurants)

A novel approach to primary prevention of CHD is

primordial prevention. Its involves preventing the

emergence and spread of CHD risk factors and life

styles that have not appeared or become endemic

36

Cont...

• Primary: Controlling risk factors contributing to

CVD (health education programs, anti-smoking

campaign, sports programs, nutrition counselling,

regular check of blood pressure and certain blood

parameters, e.g., cholesterol, blood lipids, glucose)

37

Cont……….

Secondary: Screening and treatment of symptomatic

patients, set up personal risk profile

Tertiary: Cardiovascular rehabilitation, prevention of

recurrence of CVD (new heart attack: 5-7 times higher

risk among CVD patients)

38

PREVENTION OF CHD

The WHO expert committee has recommended the

following strategy :

I. Population strategy

Prevention in whole populations

Primordial prevention in whole population

II. High risk strategy

III. Secondary prevention

39

POPULATION STRATEGY

• Control of underlying causes (risk factors) in whole

population.

• Strategy based on mass approach

• Approach based on the principle that small changes

in risk factor level in total population can achieve the

biggest reduction in mortality.

40

Specific interventions

1.Dietary Changes

Low saturated and trans fat (as low as possible below 10%

of calories).

Dietary cholesterol to below 100 mg/1000kcal/day

At least 5 fruits and vegetables/day

41

• Intake of less than 2 gm sodium (5 gm salt)/day.

• 0.4 mg of late (diet and/or supplement)

• B12, B6 from diet or multivitamin

• At least 1000 mg of calcium/day and the RDA for

magnesium

42

2.Smoking

• As far as CHD is concerned, present evidence does not support promotion of the so- called “safer cigarette”.

• The goal should be to achieve a smoke- free society an several countries are progressing towards this goal.

43

3.Blood Pressure

• Involves a multifactorial approach based on:

• Prudent diet

• Regular physical activity

• Weight control

44

Prudent diet

• Fat intake to limited to 15 to 30 percent of total cal.

• Saturated fat to limited to 10%

• Carbohydrate rich in fiber to be consumed

• Alcohol to be restricted

• Salt intake to less than 5gms

• Proteins to be 10 to 15 percent of total cal

• Junk food to be avoided.

45

3.Weight Control

• Obesity is the major risk for NIDDM and therefore CHD.

• On average, 1/2 to 1mm decrease in blood pressure for

each pound weight loss in obese hypertensive's.

• Weight reduction can raise HDL-cholesterol

46

Health Benefits of Weight Loss

• Decreased cardiovascular risk

• Decreased glucose and insulin levels

• Decreased blood pressure

• Decreased LDL and triglycerides, increased HDL

• Reduced symptoms of degenerative joint disease

• Improved gynecological conditions

47

Whenever possible, weight loss therapy should

employ the combination of

• Low-calorie/low-fat diets

• Increased physical activity

• Behavior modification

Weight Loss Therapy

48

4.Physical Activity

• Helps prevent obesity and required for long term

weight control

• Raises HDL- and lowers LDL-cholesterol

• Reduces blood pressure up to 10/8 mm Hg in

hypertensive patients (moderate activity >30 minutes

most days)

49

cont..

• Unfit men who become fit may reduce cardiovascular

disease mortality by 52% compared to those who remain

unfit.

• Recommendation is for 30 minutes of moderate activity

most days

50

HIGH RISK STRATEGY

I. Identifying risk

– Detection by screening tests

– Individuals include those who smoke, with a

strong family history of CHD, diabetes, obesity

and young women using oral contraceptives.

51

• Cont…

(ii) Specific advice

– Prevention and motivation to approach positively

against all identified risk factors.

Eg: Treatment of elevated BP

Breaking the smoking habit

Reduction of serum cholesterol levels

52

SECONDARY PREVENTION

• AIM : To prevent the recurrence and

progression of CHD.

Eg:

Coronary surgery

Use of Pacemakers

53

RISKS FACTORS INTERVENTION TRIALS

1) The North Kerelia Project (1972-) Finland

2) The Stanford -Three – Community Study (1972-75,

1980-86) USA

3) Multiple Risk factor Intervention Trial (1972-79) USA

4) Oslow diet & smoking Intervention Study(1973)

5) Lipid Research Clinics study

54

Secondary prevention trials

• At preventing a subsequent coronary attack or

sudden death. A wide range of clinical trial have been

performed with four main groups of drugs anti

coagulants , lipid lowering agents (clofibrate), anti-

thrombotic agents ( aspirin) and beta- blockers.

55

Women Making a Change

58

Wish you all a healthy heart

THANK YOU ; )