Epidemic of Cardiovascular disease
Global and US trends
Any Lessons for Honduras?
Dr. Thomas G. Allison
Cardiovascular Diseases and Internal Medicine
Mayo Clinic
Rochester, MN
Disclosures
• Conflicts of interest: none
• Off-label use of drugs or devices: none
Global Burden of Cardiovascular Disease
2002 statistics
Total deaths – 57 million
Cardiovascular
16.7 million
HIV
TB
Malaria
Developing countries
5 million
• 80% of worldwide CV deaths
• Occur at a younger age
• 2010 – 70% of the elderly will
live in the developing world
Lopez. Lancet 2006; Reddy. NEJM 2004
International Comparison
CVD Death Rates/100,000
(Men ages 35-74)
Russia
1555
714
Hungary
Poland
557
Rural China
413
USA
289
Canada
212
183
170
France
Japan
0
200
400
600
800
1000
1200
1400
1600
Cardiovascular Disease
in the Americas
Lowest
Highest
Life Expectancy in the Americas
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•
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Haiti: 55 years
Guyana: 63 years
Bolivia: 65 years
Honduras: 67 years
Brazil: 70 years
Peru: 71 years
Jamaica: 72 years
Paraguay: 72 years
Columbia: 73 years
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Mexico: 74 years
Argentina: 75 years
Uruguay: 75 years
Panama: 76 years
Costa Rica: 77 years
Chile: 77 years
Cuba: 78 years
USA: 78 years
Canada: 80 years
Modified Model of the
Epidemiological Transition as it
Pertains to Cardiovascular Disease
Yusef et al. Circulation 2001;104:276-2753
Stage 1: Age of Pestilence and Famine
Life expectancy
< 55 years
CVD deaths
5-10% of total deaths
< 5% of years of life lost (YLL)
Prominent CV diseases Rheumatic heart disease,
and risk factors
infections, nutritional
cardiomyopathies
Regional examples
Sub-Saharan Africa, rural India,
Haiti
Stage 1: Haiti
Life expectancy = 55 years
Causes of Death Haiti 2002
Cause of Death
Deaths
YLL
HIV/AIDS
22%
20%
Lower respiratory infections
7%
9%
Cerebrovascular disease
6%
3%
Meningitis
5%
7%
Diarrheal diseases
Perinatal conditions
Tuberculosis
5%
4%
4%
7%
7%
4%
Hypertensive heart disease
Anemia
Diabetes mellitus
3%
3%
3%
1%
4%
1%
Stage 2: Age of Receding Pandemics
Life expectancy
55-65 years
CVD deaths
10-35% of total deaths
Prominent CV
diseases and risk
factors
Rheumatic heart disease,
infections, nutritional
cardiomyopathies, hypertensive
heart disease, hemorrhagic strokes
Regional examples Southeast Asia, rural China,
Central and South America,
Bolivia
Stage 2: Bolivia
Life expectancy = 65 years
Causes of Death Bolivia 2002
Cause of Death
Deaths
YLL
Lower respiratory infections
9%
12%
Perinatal conditions
8%
14%
Diarrheal diseases
6%
10%
Ischemic heart disease
5%
2%
Cerebrovascular disease
Tuberculosis
Cirrhosis of the liver
4%
4%
3%
2%
4%
2%
Nephritis and nephrosis
Cervix and uterine cancers*
Diabetes mellitus
3%
2%
2%
2%
2%
1%
Stage 3: Age of Degenerative and Man-Made
Diseases
Life expectancy
65-75 years
CVD deaths
35-65% of total deaths
Prominent CV
diseases and risk
factors
All forms of stroke, ischemic
heart disease at young ages,
increasing obesity and diabetes
Regional examples
Eastern Europe, China, urban
India, Non-Hispanic Caribbean,
Jamaica
Stage 3: Jamaica
Life expectancy = 72 years
Causes of Death Jamaica 2002
Cause of Death
Deaths
YLL
Cerebrovascular disease
18%
11%
Diabetes mellitus
11%
8%
Ischemic heart disease
10%
6%
Hypertensive heart disease
6%
4%
Lower respiratory infections
HIV/AIDS
Stomach cancer
4%
4%
3%
4%
9%
2%
Nephritis and nephrosis
Perinatal conditions
Breast cancer
3%
2%
2%
3%
8%
3%
Changing Distribution of the Causes of
Death in Peoples Republic of China
Proportion of deaths (%)
100
Unknown
Injury
Other non-communicable diseases
Chronic obstructive pulmonary disease
Cerebro-cardiovascular disease
Cancer
Maternal and perinatal conditions
Communicable diseases
80
60
40
20
0
1973
2005
Year
Yang. Lancet, 2008
Stage 4: Age of Delayed Degenerative
Diseases
Life expectancy
> 75 years
CVD deaths
50% of total deaths
Prominent CV
diseases and risk
factors
Regional
examples
Stroke and ischemic heart disease at
old age
Western Europe, Australia and New
Zealand, North America, USA
Causes of Death USA 2002
Cause of Death
Deaths
YLL
Ischemic heart disease
21%
15%
Cerebrovascular disease
7%
4%
Trachea, bronchus, lung cancers
7%
7%
Chronic obstructive pulmonary disease
5%
4%
Alzheimer and other dementias
Diabetes mellitus
Colon and rectum cancers
4%
3%
3%
1%
3%
3%
Lower respiratory infections
Breast cancer
Road traffic accidents
3%
2%
2%
2%
2%
6%
Age-adjusted US CVD Disease Trends
Years
1996-2004
Nemetz et al. Arch Intern Med 2008;163:264-270
Despite decrease in Heart Disease Mortality
• Heart disease remains highly prevalent
• #1 Cause of death in US
• #1 Contributor to US health care costs
Discharges in Millions
7
6
5
4
3
2
1
0
70
75
80
85
90
95
00
06
Years
Hospital discharges for cardiovascular diseases.
(United States: 1970-2006). Note: Hospital discharges
include people discharged alive, dead and status
unknown. Source: NCHS and NHLBI.
200
Billions of Dollars
165.4
160
Total Cost = 344.9 billion dollars
120
68.9
80
73.4
37.2
40
0
Coronary Heart
Disease
Stroke
Hypertensive
Disease
Heart Failure
Estimated direct and indirect costs (in billions of dollars)
of major cardiovascular diseases and stroke
(United States: 2009). Source: NHLBI.
Transition Factors 1 → 2
Sanitation – water quality
Immunization
Antibiotics
Increased salt intake
Hypertension
Hypertensive heart disease
Hemorrhagic stroke
Population growth
Older population
Increased mechanization
of food production
More processed food
Transition Factors 2 → 3
Changing economy
Affluence
Mass media
Obesity
Diabetes
Hyperlipidemia
Ischemic Stroke
MI
Cigarette smoking
Reduced physical
activity
Increased caloric intake
More meat consumption
Incubation Period for Chronic Disease
Transition Factors 3 → 4
More educated public
Increased spending on medical care
Secondary prevention practices
Primary prevention practices
Improved survival from MI
Reduced MI, stroke at young ages
CHD Trends
McGovern et al, Circulation 2001;104:19-24
Reduction in CVD Death Rate in US
[Primary Prevention]
[Secondary Prevention]
Pre-1985 due largely to
lifestyle changes
• Smoking cessation
Post-1985 due largely to
medical management
• Coronary care units
• Electrical defibrillators
• Thrombolysis
• Emergent angioplasty
• Medical Rx
59%  25%
• Decreased dietary fat
intake
• Increased leisure-time
physical activity
McGovern et al. Circulation 2001;104:19-24
– Aspirin, beta-blockers,
ACE-inhibitors, statins
CAD Prevalence in Patients Who Died of
Unnatural Causes in Olmsted County,
et al. Arch Intern Med
MN and Had Autopsy Nemetz
2008;168:264-270
Causes of Death Honduras versus US
Where is Honduras in the
Epidemiologic Transition?
Source: Death and Daly estimates by cause, 2002
http://www.who.int/entity/healthinfo/statistics/bodfbddeathdalyestimates.xls
Causes of Death Honduras 2002
Cause of Death
Deaths
YLL
Ischemic heart disease
11%
4%
HIV/AIDS
9%
14%
Perinatal conditions
7%
13%
Cerebrovascular disease
5%
3%
Diabetes mellitus
Diarrheal diseases
Lower respiratory infections
4%
4%
4%
2%
7%
5%
Nephritis and nephrosis
Hypertensive heart disease
Protein-energy malnutrition
4%
3%
3%
2%
1%
5%
Honduras versus US
Statistics
• Life expectancy at birth
– Honduras: M = 67/F = 73 US: M = 75/F = 80
• Healthy life expectancy at birth
– Honduras: M = 56/F = 61 US: M = 67/F = 71
• Probability of dying between 15-60 years
– Honduras: M = 22.9%/F = 13.3%
– US: M = 13.7%/F = 8.0%
Honduras versus US Statistics
• Total expenditure on health per capita
– Honduras: $241
US: $6,714
• Gross national income per capita
– Honduras: $3,240
US: $44,070
• Total expenditure on health as % of GDP
– Honduras: 7.4%
US: 15.3%
World Health Statistics 2008
Financial data from 2006
Risk Factors in Honduras
• No data on hyperlipidemia for Honduras
• Hypertension highly prevalent throughout Latin
American and Caribbean
– No specific figures for Honduras
– Greater for persons of African descent
• 1 survey on diabetes in Tegucigalpa
– Prevalence 7.8%; 42% unrecognized
• 1 survey 2005-6 on females aged 15-49 for
tobacco use and obesity
– Urban > rural for both
• Tobacco use 3.7 versus 0.6%
• Obesity 23 versus 14%
Risk Factors, Honduras
Risk Factors, Honduras
Conclusions
• Honduras is moving into the age of manmade and degenerative diseases
• All risk factors will be increasing
• Honduras may not afford US high-tech
strategies for CVD prevention
In US we treat coronary disease
with devices
$93,000 USD
$26,000 USD
$5,000 USD
Some less expensive devices to
treat coronary disease
$19.95 USD
$8.09 USD
$5.95 USD
Greetings from Rochester, MN
(winter)
• Comments?
• Questions?