Cardiovascular disease Jacquelyn Ferrance, Sini Poulose Definition Cardiovascular disease is caused by disorders of the heart and blood vessels, and includes coronary heart disease (heart attacks), cerebrovascular disease (stroke), raised blood pressure (hypertension), peripheral artery disease, rheumatic heart disease, congenital heart disease and heart failure (WHO) Cardiovascular disease is a disease of the heart and diseases of the blood vessel system within a person's entire body such as the brain, legs, and lungs. In the name Cardiovascular, "Cardio" refers to the heart and "Vascular" refers to the blood vessel system. Cardiovascular Disease causes dysfunctional conditions of the heart, arteries, and veins that supply oxygen to vital lifesustaining areas of the body like the brain, the heart, and other organs. Oxygen has to carry to tissues and organs in order for a person to maintaining life. What are cardiovascular diseases? Cardiovascular diseases (CVDs) are a group of disorders of the heart and blood vessels and they include: coronary heart disease – disease of the blood vessels supplying the heart muscle; cerebrovascular disease - disease of the blood vessels supplying the brain; peripheral arterial disease – disease of blood vessels supplying the arms and legs; rheumatic heart disease – damage to the heart muscle and heart valves from rheumatic fever, caused by streptococcal bacteria; congenital heart disease - malformations of heart structure existing at birth; deep vein thrombosis and pulmonary embolism – blood clots in the leg veins, which can dislodge and move to the heart and lungs. • • • • • • CVD Facts KEY FACTS • • • • • • CVDs are the number one cause of death globally: more people die annually from CVDs than from any other cause . An estimated 17.3 million people died from CVDs in 2008, representing 30% of all global deaths. Of these deaths, an estimated 7.3 million were due to coronary heart disease and 6.2 million were due to stroke . Low- and middle-income countries are disproportionately affected: over 80% of CVD deaths take place in lowand middle-income countries and occur almost equally in men and women . The number of people who die from CVDs, mainly from heart disease and stroke, will increase to reach 23.3. million by 2030 . CVDs are projected to remain the single leading cause of death . Most cardiovascular diseases can be prevented by addressing risk factors such as tobacco use, unhealthy diet and obesity, physical inactivity, high blood pressure, diabetes and raised lipids. 9.4 million deaths each year, or 16.5% of all deaths can be attributed to high blood pressure . This includes 51% of deaths due to strokes and 45% of deaths due to coronary heart disease. CVD risk factors (WHO) Major modifiable risk factors •High blood pressure - Major risk for heart attack and the most important risk factor for stroke. •Abnormal blood lipids High total cholesterol, LDL-cholesterol and triglyceride levels, and low levels of HDL- cholesterol increase risk of coronary heart disease and ischaemic stroke. •Tobacco use Increases risks of cardiovascular disease, especially in people who started young, and heavy smokers. Passive smoking an additional risk. •Physical inactivity :Increases risk of heart disease and stroke by 50%. Other modifiable risk factors •Low socioeconomic status (SES) Consistent inverse relationship with risk of heart disease and stroke. •Mental ill-health Depression is associated with an increased risk of coronary heart disease. •Psychosocial stress Chronic life stress, social isolation and anxiety increase the risk of heart disease and stroke. CVD risk factors(WHO) Alcohol use : One to two drinks per day may lead to a 30% reduction in heart disease, but heavy drinking damages the heart muscle Use of certain medication Some oral contraceptives and hormone replacement therapy increase risk of heart disease. • Lipoprotein(a) : Increases risk of heart attacks especially in presence of high LDL-cholesterol. Left ventricular hypertrophy (LVH) : A powerful marker of cardiovascular death. Non-modifiable risk factors •Advancing age : Most powerful independent risk factor for cardiovascular disease; risk of stroke doubles every decade after age 55. •Heredity or family history : Increased risk if a first-degree blood relative has had coronary heart disease or stroke before the age of 55 years (for a male relative) or 65 years (for a female relative). •Gender : Higher rates of coronary heart disease among men compared with women (premenopausal age); risk of stroke is similar for men and women. •Ethnicity or race: Increased stroke noted for Blacks, some Hispanic Americans, Chinese, and Japanese populations. Increased cardiovascular disease deaths noted for South Asians and American Blacks in comparison with Whites. CVD risk factors (WHO) Novel risk factors •Excess homocysteine in blood (is a non-protein α-amino acid) High levels may be associated with an increase in cardiovascular risk. •Inflammation Several inflammatory markers are associated with increased cardiovascular risk, e.g. elevated C-reactive protein (CRP). •Abnormal blood coagulation Elevated blood levels of fibrinogen and other markers of blood clotting increase the risk of cardiovascular complications. CVD risk factors (WHO) Overview of CVD Globally 17 million of people die of CVDs, particularly heart attacks and strokes Heart Disease and Statistics Heart Disease and Statistics Heart Disease and Statistics Heart Disease and Statistics Coronary Heart Disease Prevalence Heart Disease and Statistics Heart Disease and Statistics Acute Myocardial Infarction Prevalence Heart Disease and Statistics Heart Disease and Statistics CVD Mortality Definition of cardiovascular health In order to accurately measure Americans’ cardiovascular health and monitor progress toward the 2020 goal, the American Heart Association for the first time defined “ideal cardiovascular health.” We define it as the absence of disease and the presence of seven key health factors and behaviors that we call “Life’s Simple 7.” Below are the measurements we use to determine whether someone is in ideal, intermediate or poor cardiovascular health. Definition of cardiovascular health Stroke (cerebrovascular) disease Definition A stroke or "brain attack" occurs when a blood clot blocks an artery (a blood vessel that carries blood from the heart to the body) or a blood vessel (a tube through which the blood moves through the body) breaks, interrupting blood flow to an area of the brain. When either of these things happen, brain cells begin to die and brain damage occurs. (National Stroke Association) Types of stroke Ischemic Stroke Embolic Stroke Thrombotic Stroke Large Vessel Thrombosis Hemorrhagic Stroke Small Vessel Disease/Lacunar Infarction Facts about stroke ● ● ● ● ● ● ● ● In the United States, stroke is the fourth leading cause of death, killing over 133,000 people each year, and a leading cause of serious, long-term adult disability. There are an estimated 7,000,000 stroke survivors in the U.S. over age 20. Approximately 795,000 strokes will occur this year, one occurring every 40 seconds, and taking a life approximately every four minutes. Stroke can happen to anyone at any time, regardless of race, sex or age. From 1998 to 2008, the annual stroke death rate fell approximately 35 percent, and the actual number of deaths fell by 19 percent. Approximately 55,000 more women than men have a stroke each year African Americans have almost twice the risk of first-ever stroke compare with whites. Stroke Prevalence ● An estimated 6 .8 million Americans ≥20 years of age have had a stroke (extrapolated to 2010 by use of NHANES 2007–2010 data) . Overall stroke prevalence during this period is an estimated 2 .8% (NHANES, NHLBI) . ● According to data from the 2012 BRFSS (CDC), 2 .9% of men and 2 .9% of women ≥18 years of age had a history of stroke; 3 .0% of non-Hispanic whites, 3 .8% of non- Hispanic blacks, 1 .9% of Asian/Pacific Islanders, 1 .8% of Hispanics (of any race), 5 .8% of American Indian/Alaska Natives, and 4 .1% of other races or multiracial people had a history of stroke . The prevalence of silent cerebral infarction is estimated to range from 6% to 28%, with higher prevalence with increasing age . ● Projections show that by 2030, an additional 3 .4 million people aged ≥18 years will have had a stroke, a 20 .5% increase in prevalence from 2012 . The highest increase (29%) is projected to be in Hispanic men . Stroke prevalence Estimated 10 year- Stroke risk Stroke Incidence ● Each year, ≈795 000 people experience a new or recurrent stroke . Approximately 610000 of these are first attacks, and 185 000 are recurrent attacks (GCNKSS, NINDS, and NHLBI; GCNKSS and NINDS data for 1999 provided July 9, 2008; estimates compiled by NHLBI) . ● Of all strokes, 87% are ischemic and 10% are ICH strokes, whereas 3% are SAH strokes (GCNKSS, NINDS, 1999) ● On average, every 40 seconds, someone in the United States has a stroke (AHA computation based on the latest available data) ● Each year, ≈55000 more women than men have a stroke (GCNKSS, NINDS) ● Women have a higher lifetime risk of stroke than men . In the FHS, lifetime risk of stroke among those 55 to75 years of age was 1 in 5 for women (20% to 21%) and ≈1 in 6 for men (14% to 17%) . Stroke Incidence ● The age-adjusted incidence of first ischemic stroke per 1000 was 0.88 in whites, 1 .91 in blacks, and 1 .49 in Hispanics according to data from NOMAS (NINDS) for 1993 to 1997 . Among blacks, compared with whites, the relative rate of intracranial atherosclerotic stroke was 5 .85; of extracranial atherosclerotic stroke, 3 .18; of lacunar stroke, 3 .09; and of cardioembolic stroke, 1 .58 . Among Hispanics (primarily Cuban and Puerto Rican), compared with whites, the relative rate of intracranial atherosclerotic stroke was 5 .00; of extracranial atherosclerotic stroke, 1 .71; of lacunar stroke, 2 .32; and of cardioembolic stroke, 1 .42 . TIA: Prevalence, Incidence, and Prognosis ● In a nationwide survey of US adults, the estimated prevalence of self-reported physiciandiagnosed TIA was 2.3%, which translates to ≈5 million people. ● The prevalence of physician-diagnosed TIA increases with age. Incidence of TIA increases with age and varies by sex and race/ethnicity. Men, blacks, and Mexican Americans have higher rates of TIA than their female and non- Hispanic white counterparts. TIAs confer a substantial short-term risk of stroke, hospitalization for CVD events, and death. Of 1707 TIA patients evaluated in the ED of Kaiser Permanente Northern California, 180 (11%) experienced a stroke within 90 days. Ninety-one patients (5%) had a stroke within 2 days. Individuals who have a TIA and survive the initial high risk period have a 10-year stroke risk of roughly 19% and a combined 10-year stroke, MI, or vascular death risk of 43% (4% per year) Within 1 year of TIA, ≈12% of patients will die. ● ● Recommendations on TIA prevention ● Recommendations for Modifiable Behavioral Risk Factors (cigarette smoking, alcohol consumption) ● Recommendations for Treatable Vascular Risk Factors (Hypertension, diabetes Mellitus) ● Recommendations for Patients With Cardioembolic Stroke Types (Acute MI and LV thrombus) ● Recommendations for Antithrombotic Therapy for Noncardioembolic Stroke or TIA (Oral Anticoagulant and Antiplatelet Therapies) Guidelines for the Prevention of Stroke in Patients With Stroke or Transient Ischemic Attack (AHA/ASA Guidline) Stroke Risk Factors High Blood Pressure Diabetes Mellitus High Blood Cholesterol and Other Lipids Disorders of Heart Rhythm High Blood Cholesterol and Other Lipids Smoking Physical Inactivity Family History and Genetics Chronic Kidney Disease Nutrition Risk Factor Issues Specific to Women ● On average, women are older at stroke onset than men (≈75 years compared with 71 years). ● Analysis of data from the FHS found that women with natural menopause before 42 years of age had twice the ischemic stroke risk of women with natural menopause after 42 years of age. ● Investigators from the Nurse’s Health Study, however, did not find an association between age at natural menopause and risk of ischemic or hemorrhagic stroke. ● Migraine with aura is associated with ischemic stroke in younger women, particularly if they smoke or use oral contraceptives. The combination of all 3 factors increases the risk ≈9-fold compared with women without any of these factors Stroke in the Very Elderly ● Stroke patients >85 years of age make up 17% of all stroke patients. ● According to analyses from the US Nationwide Inpatient Sample, over the past decade, in-hospital mortality rates after stroke have declined for every age/sex group except men aged >84 years . ● Over the next 40 years (2010–2050), the number of incident trokes is expected to more than double, with the majority of the increase among the elderly (aged ≥75 years) and minority groups . Aftermath of stroke ● Stroke is a leading cause of serious long-term disability in the United States (Survey of Income and Program Participation, a survey of the US Census Bureau) . Approximately one third of stroke survivors experience poststroke depression . ● Visual impairments persist in 21% of stroke survivors 90 days after stroke . ● After stroke, women have greater disability than men ● In the NHLBI’s FHS, among ischemic stroke survivors who were ≥65 years of age, the following disabilities were observed at 6 months after stroke: —50% had some hemiparesis —30% were unable to walk without some assistance —46% had cognitive deficits —35% had depressive symptoms —19% had aphasia —26% were dependent in activities of daily living —26% were institutionalized in a nursing home Stroke Mortality ● On average, every 4 minutes, someone dies of a stroke (NCHS, NHLBI). ● Stroke accounted for ≈1 of every 19 deaths in the United States in 2010. ● When considered separately from other CVDs, stroke ranks No. 4 among all causes of death, behind diseases of the heart, cancer, and CLRD (NCHS mortality data). ● More women than men die of stroke each year because of the larger number of elderly women. Women accounted for almost 60% of US stroke deaths in 2010 (AHA tabulation). ● Conclusions about changes in stroke death rates from 1981 to 2009 are as follows:There was a greater decline in stroke death rates in men than in women, with a male-to-female ratio that decreased from 1.11 to 1.05 (age adjusted). ● Stroke death rates declined more in people aged 45 to 64 years (−51.7%) than in those ≥65 years of age (−48.3%) or those aged 18 to 44 years (−37.8%). The decline in stroke mortality ● cardiovascular risk factor control interventions. ● hypertension control efforts initiated in the 1970s , with lower blood pressure distributions in the population. ● Control of DM and dyslipidemia, as well as smoking cessation programs, ● In examining trends in stroke mortality by US census divisions between 1999 and 2007 for people ≥45 years of age, the rate of decline varied by geographic region and race/ ethnic group. Among black and white women and white men, rates declined by ≥2% annually in every census divi- sion, but among black men, rates declined little in the East and West South Central divisions. ● Average stroke mortality is ≈20% higher in the stroke belt than in the rest of the nation and ≈40% higher in the stroke buckle. Financial Impact • In 2010 the estimated cost of cardiovascular disease in America was $444 billion (CDC.gov) o • Roughly $1 out of every $6 spent on healthcare in America Prevention programs sponsored by the CDC cost $56.2 million in 2010 Financial Impact (Heidenreich et al, 2011) Financial Impact (Heidenreich et al, 2011) Framingham Heart Study ● Original cohort in 1948 ● Children of cohort (generation 2) recruited in 1971 ● Omni Cohort enrolled in 1994 ● Grandchildren of original cohort (generation 3) recruited in 2002 ● Second Omni Cohort in 2003 (Framinghamheartstudy.org) The Jackson Study • • • Collaboration of American Heart Association and University of Mississippi Adds racial diversity to previous data Provides education to the Jackson community (jacksonheartstudy.org) Prevention: American Heart Association • • • • 2020 Goals Local Chapters Research funding Guidelines for Providers (heart.org) Policy Change • • • Sodium Reduction Initiative o Companies that signed include: Boar’s head, campbells soup, Kraft, Starbucks, Subway, Target National Heart Disease and Stroke Prevention Programs Smoking Bans (cdc.gov) Prevention • • • • The Million Hearts Initiative(CDC Grand Rounds, 12 Dec 2012) Million Hearts Virginia (VDH.virginia.gov) Healthy People 2020 (healthypeople.gov) Stroke Belt Elimination Initiative (minorityhealth.hhs.gov) Primary Prevention • • • • • • • Controlling Hypertension Lowering Cholesterol Eliminating Tobacco use Well-Balanced Diet Controlling Weight Exercise Limiting Alcohol Intake (CDC.gov, American Heart Association) Overview Logic Model (CDC.gov) Expanded Logic Model (CDC.gov) Secondary Prevention • • • Frequent Blood Pressure Screenings Serum Cholesterol Screening Electrocardiograms are not recommended for the general population Treatments • • • • Lifestyle Programs Medication Surgery Gene Therapy Treatment: Medication ● ● ● ● ● ● ● Statins (Psaty & Weiss, 2014) Blood Thinners Diuretics Beta Blockers ACE inhibitors Antiplatelet Agents Vasodilators (heart.org) Treatment: Surgery • • • • Angioplasty Artificial Heart Valve Bypass Surgery Stent Procedure (heart.org) Future Research • • • • National Surveillance System Role of plasma C-reactive protein, fibrinogen, homocysteine, and serum cholesterol Coordinated Community Intervention Trials Quality of Life Research References • • • • • • • "Framingham Heart Study." Framingham Heart Study. National Heart, Lung, and Blood Institute. Web. 06 Feb. 2014. Heidenreich, P. A., et al. "Forecasting the Future of Cardiovascular Disease in the United States: A Policy Statement From the American Heart Association." Circulation 123.8 (2011): 933-44. Print. Ioannidis, John. "More Than a Billion People Taking Statins? Potential Implicaions of the New Cardiovascular Guidelines." Journal of the American Medical Association 311.5 (2014): 463-64. Print. "Jackson Heart Study." Jackson Heart Study. Web. 07 Feb. 2014. Khurana, R., J. F. Martin, and I. Zachary. "Gene Therapy for Cardiovascular Disease: A Case for Cautious Optimism." Hypertension 38.5 (2001): 1210-216. Print. Montori, Victor, Juan Brito, and Henry Ting. "Patient-Centered and Practical Application of New High Cholesterol Guidelines to Prevent Cardiovascular Disease." Journal of the American Medical Association 211.5 (2014): 46566. Web. Pearson, T. A., L. P. Palaniappan, N. T. Artinian, et al. "American Heart Association Guide for Improving Cardiovascular Health at the Community Level, 2013 Update: A Scientific Statement for Public Health Practitioners, Healthcare Providers, and Health Policy Makers." Circulation 127.16 (2013): 1730-753. Print. References • • • • Pandya, A., T. A. Gaziano, M. C. Weinstein, and D. Cutler. "More Americans Living Longer With Cardiovascular Disease Will Increase Costs While Lowering Quality Of Life." Health Affairs 32.10 (2013): 1706-714. Print. Psaty, Bruce, and Noel Weiss. "2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol A Fresh Interpretation of Old Evidence." Journal of the American Medical Association 311.5 (2014): 461-62. Print. United States of America. Centers for Disease Control and Prevention. CDC Grand Rounds: The Million Hearts Initiative. CDC, 21 Dec. 2012. Web. 07 Feb. 2014. United States of America. Department for Health and Human Services. Center for Disease Control and Prevention. CDC State Heart Disease and Stroke Prevention Guide Evaluation Framework. Print.