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Prevention of Cardiovascular Diseases:

Begin in Childhood!Ruth Collins-NakaiMD, MBA, FRCPC, FACC

President

InterAmerican Society of Cardiology

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Outline

World status of CVDs

Argentinean status of CVDs

Prevention efficacy

Recommendations re risk factors

Role of CV specialist in prevention

04/19/231999 WHF "Impending Global

Pandemic of CVDs4

World Status of CVD

Represents 30% of all deaths worldwide

(15 million deaths/year)

Leading cause of death and disability

CVD burden in developing countries

Risk factors worldwide

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% GDP spent on health

04/19/23 http://cvdinfobase.ic.gc.ca 6

Population per Physician

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Argentina CVD mortality: females

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Argentina CVD mortality: females

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Argentina IHD mortality: males

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Argentina Diabetes: females males

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Atherosclerosis: A Systemic Disease

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Prevention Facts Defined Risk Factors in adults associated

with accelerated atherosclerosis and CVD rates*

Atherosclerosis begins in childhood * * Extent of atherosclerosis in children

correlated with same risk factors as in adults * * *

*Strong JP et al JAMA 1999;281:727-735

* Berenson GS et al NEJM 1998;338:1650-1656

* * *Williams CL et al Circ. 2002;106:143-160

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0

20

40

60

80

%

Age (Years)

Aorta Coronary Arteries

2-15 16-20 21-25 26-39 2-1516-20 21-2526-39

p = 0.001 for trend toward increasing prevalence with age in aorta

and coronary arteries.

Early Appearance of Atherosclerosis:

Bogalusa Heart StudyPrevalence of Fibrous Plaque Lesions

0

20

40

60

80

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The Evidence physical activity associated with life

expectancy Direct association between obesity &

insulin resistance in children Direct association between obesity & lipid

levels in children Tracking: BMI>weight>skinfold

thicknesses>lipids>BP Clusters of multiple risk factors persist

strongly from child-to-adulthood

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Risk Factors for Atherosclerosis

Smoking Obesity High blood pressure Physical Inactivity High blood fat levels Diabetes Positive family history Other (ethnicity, anger)

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0

6

12

18

24

30

36

42

10-Year %

Probability

of Event

SBP 150-160 + + + + + +Cholesterol 6.2-6.8 - + + + + +HDL-C 0.8-0.9 - - + + + +Diabetes - - - + + +Cigarettes - - - - + +ECG-LVH - - - - - +

4 610

14

21

40

Effect of Multiple Risk Factors on Probability of CAD: Framingham Study

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Recommendations

Cardiovascular Health in Childhood (AHA Scientific Statement) Circ 2002;106:143-160 Circ 2002;107:1562-1566

Canadian Cardiovascular Society Consensus Conference on Prevention of CVD: The Role of the CV Specialist CJC 1999;15(supple.G)

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Smoking

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Tobacco

Complete cessation for those who

smoke

No exposure to environmental

tobacco smoke

No new initiation of cigarette

smoking or tobacco use

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Obesity Appropriate body weight (BMI for age)

(www.cdc.gov/growthcharts./)

Overall healthy eating pattern (limit salt,

fat, calories & sugar > 2 years age)

Balance “Energy in = energy out” for

weight

Begin treatment before adolescence

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20

15

10

5

0

6-11 yrs 12-19 yrs

1963-70 1971-74 1976-80 1988-94 1999

Trends in prevalence of overweight in USA(CDC – NHANES)

%

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Physical Activity

Physical activity every day (60

minutes per day for children)

Reduce/limit sedentary time (e.g..

TV maximum 2 hours per day)

May add resistance training to

aerobic activity in adolescents

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Lipids & Lipoproteins

Total cholesterol <4.4 mmol/L recommended

(USA>170mg/dL borderline; >200 mg/dL is )

LDL-C <2.85 mmol/L recommended

(USA<110mg/dL)

Triglycerides <1.5 mmol/L recommended

(USA <150 mg/dL)

HDL-C >35 mg/dL recommended

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CAD Death Rate per 10,000 Person-years

100+ 90-99

80-89

75-79

70-74

<70<120

120-139140-159

160+

Diastolic BP (mmHg)Systolic BP (mmHg)

20.610.3 11.8 8.8 8.5 9.2

11.8

12.6

12.8

13.9

24.6

25.3

25.2

24.9

16.9

23.8

31.0

25.8

34.7

43.8

38.1

80.6

37.4

48.3

Effect of SBP and DBP onAge-Adjusted CAD Mortality: MRFIT

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Blood Pressure

Systolic & diastolic BP>90th% for age,

sex and height is abnormal

(www.nhlbi.nih.gov/health/prof/heart/hbp/

hbp_ped.htm.)

>130/~80 is almost always pathological

in youth.

Use proven effective therapies

recommended for adults (CPGs)

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Diabetes Adequate nutrition (neither over

nor undernutrition) of pregnant women: Barker hypothesis

Limit sugar intake Maintain normal weight for age &

height For type 1 diabetics, ongoing

strict control (Hgb A1c)

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Ethnicity (esp. South Asian / aboriginal/black/Hispanic)

Low socioeconomic level

Social isolation

Depression

Pregnancy (HTN and gestnl diabetes)

“Emerging” risk factors

Other Risk Factors

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Childhood Abuse Adverse childhood experiences

(ACEs) 1.7x risk with emotional abuse 1.7x risk with crime in

household 1.3x risk with emotional neglect 1.3x risk with substance abuse Depressed affect OR 2.1 Anger: OR 2.5 7 or > ACEs risk almost 4x

Dong M et al CIRC 110; 2004

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--

Specialized medicine

First line medicine

Clinical Application of the Concept of Risk

Vascular, unstable

Asymptomatic

VascularDiabetic

Asymptomatic + risk factors

Primary prevention Secondary prevention

Diabetic + risk factors

Pluri-vascular

Lo

wH

igh

Hyp

er

Ris

k

Symptomatic

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Economic Burden of Coronary Artery Disease (CAD)

US (2000) $118.2 billion USD

Canada (1993) $19.6 billion CDN (15.2% of total economic burden of illness)

UK (1996) £10 billion

Germany (1996) 112 billion DM

Taiwan (1991) 9.0-11.9 billion new Taiwan $

Sweden (1994) 276 billion SEK

Direct and Indirect Cost of CAD Country (not adjusted for inflation)

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BMI

<75%ile 75-85%ile85-95%ile

at risk for ow >95%ile

overweight

Reaffirm healthy Habits;

f/u annually

Assess family history,

food habits,activity

Council to change food

intake;increase physical activity

Council to change food

intake;increase physical activity

Assess RF;If >1 RF, treat as >95%ile

Assess RF;Treat RFs;

Involve family

Nesbitt SD et alEthnicity & Disease 14;2004

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Role of Cardiovascular Specialist

Education of other health care

personnel

Advocate for heart healthy public

policies

Treat individual patients, including

children with significant risk factors.

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Conclusions

The burden of global CVD is increasing

The burden of risk factors is rising alarmingly in children and youth

Cardiovascular specialists have an obligation to lead in prevention

Educate, Advocate, Treat

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Gracias!

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Questions for readers of Prevention of Cardiovascular Diseases: Begin in Childhood! lecture by Ruth Collins-Nakai(developed by Supercourse Team)

• At what age do we begin to see fatty streaks associated with atherosclerosis?•What is the difference in risk from the lowest to highest risk factors•Why should we intervene with children to prevent MIs 60 years later?