Epidemiology of Cardiovascular Disease Presentation Overview • Background • Incidence/Prevalence • Attributes associated with cardiovascular disease • Costs • Interventions • Current and future research Background Including incidence/prevalence Four Main Diseases • Coronary heart disease (CHD) • Heart failure (HF) • Stroke • Peripheral artery disease (PAD) Coronary Heart Disease • also known as ischemic heart disease, coronary artery disease • attributed to reduced blood flow to the heart • most often caused by atherosclerosis • results in angina (chest pain), myocardial infarction (a.k.a. heart attack), and death Atherosclerosis • thickening of artery walls —> narrowing of arteries —> decreased blood flow —> increased risk of embolism (blood clot) • factors that contribute to development: • • inflammation • calcification • deposit of fat/cholesterol process begins in childhood; fetal factors may be involved Incidence of CHD • “Every 43 seconds, someone in the United States has a heart attack” - Center for Disease Control • Every year there are approximately 1.2 million new or recurrent heart attacks in the U.S. Prevalence of CHD • An estimated 80 million Americans have one or more CVD • CHD accounts for 52% of CVD deaths • death rates from CHD peaked in 1963 and have steadily been decreasing since 1968 • 26% decline in death rates from CVD overall from 1995-2005 Heart Failure • inability of either left or right ventricle to properly fill with or eject blood secondary to damaged or weakened heart muscles • shortness of breath + fatigue —> decreased exercise tolerance + fluid retention —> pulmonary and peripheral edema —> decreased quality of life • left vs right heart failure Incidence and Prevalence of HF • Approximately 25% of men and 45% of women will develop HF within 6 years of having a heart attack • HF is the one CVD that is increasing in incidence, prevalence, and mortality • CVD is the leading cause of disability in the U.S. Attributes associated with CVD Race/Ethnicity - CVD - leading cause of death in U.S. for whites, blacks, and American Indians - Age-adjusted CVD mortality rates (per 100,000) • 438 for African American men • 325 for white men • 319 for AA women • 230 for white women - Hispanics and Asian Americans appear to be at lower risk of heart disease and stroke mortality than whites http://www.cdc.gov/heartdisease/family_history.htm Age • Mortality greater among older adults • increases independent of other known risk factors • 55% of heart attacks are in those 65+; 85% of deaths from MI are in those 65+ • CHD incidence rates in women after menopause are 2-3x higher than those women pre-menopausal of the same age Sex • Age-adjusted mortality 45% higher in men • Still leading cause of death in U.S. women • CHD incidence for women lags behind men by 10 years Geography http://www.cdc.gov/dhdsp/maps/national_maps/hd_hospitalization_all.htm http://www.cdc.gov/dhdsp/maps/national_maps/hd65_all.htm http://www.cdc.gov/dhdsp/maps/sd_poverty.htm Socioeconomic Status • CHD incidence and mortality higher in those of lower SES • so far, greatest decline in CHD mortality has been seen in white men/women with the highest levels of education/income • living in “deprived” neighborhoods linked with increased risk factors Global Perspective • Mortality rates remain higher in U.S. than many other industrialized nations • 2020 Projections: • Latin America, the Middle East, and subSaharan Africa will have 3x the occurrence of heart disease from 1990-2020 • rates in developing countries will increase 120% for women, 137% for men Adverse Behaviors • Poor diet • Lack of physical activity • Smoking • Alcohol consumption All which can contribute to…obesity, diabetes, high blood pressure, high cholesterol Cost • $151.6 billion = 2004 estimated cost of medical care, lost earnings, and lost productivity • $475 billion = 2009 estimated direct and indirect costs of CVD per AHA • HF specifically - high hospitalization rates and poor prognosis, strain on Medicare • 3 most prominent factors influencing economic burden: • revascularization procedures • hospital care • prescription medications http://www.commed.vcu.edu/Chronic_Disease/Heart/prevstrat_21Cent.pdf http://www.commed.vcu.edu/Chronic_Disease/2010/orprevhtataglance.pdf Interventions Primary, secondary, tertiary, community-level Primary Prevention • • • Control of modifiable risk factors • decrease cholesterol/systolic BP/smoking/physical inactivity • recent efforts in this area have accounted for 44% decline in CHD mortality • efforts partially offset by increases in BMI and diabetes Environmental changes Million Hearts Initiative http://www.commed.vcu.edu/Chronic_Disease/Heart/2012/cvsnatpolicy.pdf http://millionhearts.hhs.gov/about-million-hearts/million-hearts.html Secondary Prevention • Screening for high blood pressure/cholesterol • Electrocardiograms for high risk individuals Tertiary Prevention • Revascularization - stents, coronary artery bypass grafts • Cardiac rehab - prevention of complications through diet, exercise, weight control, and smoking cessation • Medications - statins, diuretics, beta blockers • Mechanical assist devices - pacemakers, LVAD Community-level • use education and environmental changes to promote positive lifestyle and behavior changes • North Karelia Project • began in 1972 • studied risk factor interventions • interventions directed at the media and food producers/distributors http://www.commed.vcu.edu/Chronic_Disease/Heart/2014/commguideAHA2013.pdf Healthy People 2020 • Many goals related to heart disease, including: • reduce proportion of adults with hypertension (from 29.9 to 26.9%) • reduce proportion of adults with high total blood cholesterol levels (from 15.0 to 13.5%) https://www.healthypeople.gov/2020/topics-objectives/topic/heart-disease-andstroke/objectives?topicId=21 Research Current/Future/Issues Framingham Heart Study • began in 1948, conducted by National Heart Institute • primary aim: identify factors and characteristics contributing to CVD • enrolled ~5,200 men and women with no overt signs/symptoms of disease, examining them every two years • allowed for the identification of key risk factors http://www.framinghamheartstudy.org/about-fhs/history.php Gene/Stem Cell Therapy • Interest in using both therapies to aid in repair of damaged tissue • controversial • needs further study in humans http://www.commed.vcu.edu/Chronic_Disease/Heart/2012/cvschallenges2011.pdf Link Between Cholesterol and CVD • Landmark study published in 1966 • Looked at link between HDL and heart disease • Importance of looking to past research to advance current knowledge • http://www.commed.vcu.edu/Chronic_Disease/Heart/revisiiti ngpastrsch.pdf Cholesterol in Children • Report from National Center for Health Statistics analyzing data from NHANES • Children 6-19 years old • Key findings: • Approximately 1/5 children and adolescents had at least one abnormal cholesterol measure (high total cholesterol, low HDL cholesterol, or high nonHDL cholesterol) • Those who were obese had 5x prevalence of low HDL levels compared to normal weight • American Academy of Pediatrics recommends monitoring cholesterol in all children • Long-term monitoring may inform public health interventions and prevent CVD as an adult http://www.cdc.gov/nchs/data/databriefs/db228.htm Diet Considerations • U.S. Dietary Guidelines Advisory Committee released 2015 Dietary Guidelines recommendations • May see dietary cholesterol removed from list of “nutrients of concerns” • Eliminate a limit on total fat consumption • • type more important that quantity http://www.commed.vcu.edu/Chronic_Disease/Heart/2016/BMJEditFood Obj.pdf Gaps in Knowledge • Role of genetics - inflammatory biomarkers and signaling pathways • Public health implementation science - role of social networks, transportation, media, etc. • • more community-based studies needed Population-based prevention research • especially for minority populations, women/children http://www.commed.vcu.edu/Chronic_Disease/Heart/2012/cvsnatpolicy.pdf Gaps, cont. • Understanding of causes of HF is still not well known; prognosis still very poor • Optimal range for BP meds and lipid-lowering meds still unclear • too lenient vs too aggressive http://www.commed.vcu.edu/Chronic_Disease/Heart/2012/cvschallenges2011.pdf Other Road Blocks Delayed clinical implementation • • ability to understand applicability of new findings/technologies • beta blockers - routinely prescribed 25 years after publication of definitive randomized trials on their benefits for post MI survivors COST • • • of research itself - difficult and expensive to conduct large-scale randomized trials • of different primary prevention methods - prescribing more meds does not seem to be cost effective Current agricultural policies http://www.commed.vcu.edu/Chronic_Disease/Heart/2012/cvschallenges2011.pdf http://www.commed.vcu.edu/Chronic_Disease/Heart/2012/cvsnatpolicy.pdf http://www.commed.vcu.edu/Chronic_Disease/Heart/prevstrat_21Cent.pdf http://www.commed.vcu.edu/Chronic_Disease/Heart/2015/altresearchstrat..pdf References Remington, P. L., Brownson, R. C., & Wegner, M. V. (2010). Chronic disease epidemiology and control. Washington, DC: American Public Health Association. Questions?
