Controlling Cardiovascular Controlling Cardiovascular Disease (CVD)Disease (CVD)

Dr Farid NajafiDr Farid NajafiSchool of Population HealthSchool of Population Health

Kermanshah University of Medical Kermanshah University of Medical SciencesSciences

ObjectivesObjectives

DefinitionDefinition Coronary artery diseaseCoronary artery disease StrokeStroke

Burden of DiseaseBurden of Disease GlobalGlobal RegionalRegional

Trends Trends Developed countriesDeveloped countries Developing countriesDeveloping countries

Risk FactorsRisk FactorsPreventionPreventionFutureFuture

DefinitionDefinition

A group of disorders of the heart and A group of disorders of the heart and blood vessels and include:blood vessels and include: Coronary artery diseaseCoronary artery disease Cerebrovascular diseaseCerebrovascular disease Peripheral arterial diseasePeripheral arterial disease Rheumatic heart diseaseRheumatic heart disease Congenital heart diseaseCongenital heart disease Deep vein thrombosis and pulmonary Deep vein thrombosis and pulmonary

embolismembolism

Coronary artery disease (CAD) or Coronary artery disease (CAD) or coronary heart disease (CHD)coronary heart disease (CHD)

Definition and example:Definition and example:

Disease of the blood vessels supplying the Disease of the blood vessels supplying the heart muscle- Angina and acute heart muscle- Angina and acute myocardial infarction are two important myocardial infarction are two important type of CADtype of CAD

StrokeStroke

Definition:Definition:

Disruption of the blood supply to the brainDisruption of the blood supply to the brain

Classification:Classification:

1.1. Ischaemic stroke: blockage of blood Ischaemic stroke: blockage of blood vesselsvessels

2.2. Haemorrhagic stroke: rupture of the Haemorrhagic stroke: rupture of the blood vesselsblood vessels

Significance of CVDSignificance of CVD(Public Health)(Public Health)

Leading cause of mortality in developed Leading cause of mortality in developed countries and a rising tendency in countries and a rising tendency in developing countriesdeveloping countries

Significantly contributes to morbidity and Significantly contributes to morbidity and death rates in the middle aged population: death rates in the middle aged population: major contribution to DALYs and economic major contribution to DALYs and economic costcost

Cause of 30% of morbidity in populationCause of 30% of morbidity in population

Different parts of CVD Different parts of CVD epidemiologyepidemiology

1.1. Descriptive epidemiologyDescriptive epidemiologyPerson, Time, PlacePerson, Time, Place

2.2. Analytic epidemiologyAnalytic epidemiologyRelationship between CVD and risk factorsRelationship between CVD and risk factors

3.3. Experimental epidemiologyExperimental epidemiologyStrategies for prevention of CVD (primary, Strategies for prevention of CVD (primary, secondary and tertiary)secondary and tertiary)

Descriptive epidemiologyDescriptive epidemiologyGlobal patternGlobal pattern

Number one cause of death globally (30%)Number one cause of death globally (30%)

In 2005, 17.5 million deaths from CVDs, In 2005, 17.5 million deaths from CVDs, mainly from CAD and stroke=30% of all mainly from CAD and stroke=30% of all deathsdeaths

>80% of CVD deaths in low- and middle->80% of CVD deaths in low- and middle-income countriesincome countries

CVD remain the single leading cause of CVD remain the single leading cause of death till 2015death till 2015

Mathers and loncar, 2006

Mathers and loncar, 2006

Descriptive epidemiologyDescriptive epidemiologyImportance of chronic conditions in Importance of chronic conditions in

IranIranCommunicable, maternal, perinatal and Communicable, maternal, perinatal and nutritional: 3338 DALY per 100,000 (18%)nutritional: 3338 DALY per 100,000 (18%)

Noncommunicable diseases: 16563 DALY Noncommunicable diseases: 16563 DALY per 100,000 (59%)per 100,000 (59%)

Injury: 4326 DALY per 100,000 (23%)Injury: 4326 DALY per 100,000 (23%) Conclusion: Chronic conditions are major Conclusion: Chronic conditions are major

public health problems in Iran and need public health problems in Iran and need more investigationsmore investigations

WHO, December 2004

Burden of Illness - CVDBurden of Illness - CVD

Number one cause of death globally (30%)Number one cause of death globally (30%)26% of all deaths in EMRO in 2002.26% of all deaths in EMRO in 2002.The prevalence of heart, stroke and vascular The prevalence of heart, stroke and vascular conditions increased over the last decade.conditions increased over the last decade.12% of total burden in 200212% of total burden in 2002The total burden of heart, stroke and vascular The total burden of heart, stroke and vascular diseases is expected to increase over the diseases is expected to increase over the coming decades due to the growing number of coming decades due to the growing number of elderly people, among whom these diseases are elderly people, among whom these diseases are most common.most common.

Descriptive epidemiologyDescriptive epidemiologyAgeAge

Death due to CVD in different age groupsDeath due to CVD in different age groups Pathologic process (atherosclerotic plaques) Pathologic process (atherosclerotic plaques)

starts from 20 years ago-lifestyle patterns starts from 20 years ago-lifestyle patterns start from childhood and youth (smoking, start from childhood and youth (smoking, dietary habits, sport, etc.)dietary habits, sport, etc.)

CVD morbidity and mortality: increase in CVD morbidity and mortality: increase in middle age-group (30-44)middle age-group (30-44)

Premature death (<64)Premature death (<64)

Descriptive epidemiologyDescriptive epidemiologySexSex

CVD among men and women:CVD among men and women: CVD is a prevalent condition among middle-CVD is a prevalent condition among middle-

aged menaged men Fatal cases are more common among menFatal cases are more common among men Equal number of women are affected (older Equal number of women are affected (older

age group)age group)

Descriptive epidemiologyDescriptive epidemiologysexsex

WomenWomen Higher risk in women than men (triglyceride Higher risk in women than men (triglyceride

level)level) Higher prevalence of certain risk factors in Higher prevalence of certain risk factors in

women (diabetes, depression, response to women (diabetes, depression, response to stress)stress)

Gender-specific risk factors:Gender-specific risk factors:1.1. Oral contraceptive pills Oral contraceptive pills 2.2. hormone replacement therapyhormone replacement therapy3.3. Polycystic ovary syndromePolycystic ovary syndrome

Descriptive epidemiologyDescriptive epidemiologyTime and placeTime and place

Developed countries: DecreasingDeveloped countries: Decreasing Improvement of lifestyle factors, such as: a Improvement of lifestyle factors, such as: a

decrease of smoking and higher level of decrease of smoking and higher level of health consciousnesshealth consciousness

Better diagnosis and treatment of underlying Better diagnosis and treatment of underlying causescauses

Developing countries: IncreasingDeveloping countries: Increasing Aging, western lifestyle, smoking, urbanizationAging, western lifestyle, smoking, urbanization

Mathers and Loncar, 2006

Analytic epidemiologyAnalytic epidemiologyCausation Causation

Over 300 factors have been known as risk Over 300 factors have been known as risk factors for CVDfactors for CVD75% of CVD is due to conventional risk 75% of CVD is due to conventional risk factors with greatest public health factors with greatest public health importance:importance: High prevalence in different populationHigh prevalence in different population Great independent effect on CVDGreat independent effect on CVD Their control has major effect on decrease of Their control has major effect on decrease of

burden of CVDburden of CVD

Analytic epidemiologyAnalytic epidemiologyRisk factorsRisk factors

Major modifiable Major modifiable High BPHigh BP Abnormal blood lipidAbnormal blood lipid SmokingSmoking Physical inactivityPhysical inactivity ObesityObesity Unhealthy dietUnhealthy diet DiabetesDiabetes

Non-modifiableNon-modifiable AgeAge Gender (male)Gender (male) Family historyFamily history RaceRace

Other modifiableOther modifiable Low SESLow SES Mental ill health (Depression)Mental ill health (Depression) StressStress Heavy alcohol useHeavy alcohol use Lipoprotein aLipoprotein a Certain medicationCertain medication

““Novel risk factorsNovel risk factors Excess homocysteineExcess homocysteine Inflammatory markersInflammatory markers Abnormal blood coagolation Abnormal blood coagolation

( high level of fibrinogen)( high level of fibrinogen)

Current evidence suggest that smoking, BP, blood lipids and physical inactivity Current evidence suggest that smoking, BP, blood lipids and physical inactivity can explain greater then 80%can explain greater then 80%

Risk factors in developing countriesRisk factors in developing countries

High blood pressureHigh blood pressure

Definition:Definition: A systolic blood pressure above 140 mmHg and/or a A systolic blood pressure above 140 mmHg and/or a

diastolic blood pressure (DBP) above 90 mmHgdiastolic blood pressure (DBP) above 90 mmHg

One of the most important preventable causes of One of the most important preventable causes of premature death worldwidepremature death worldwideEven a BP at the top end of the normal range Even a BP at the top end of the normal range increases risk of CVDincreases risk of CVDBP rises with age, salt intake, low physical BP rises with age, salt intake, low physical atctivity and obesityatctivity and obesityControl of high blood pressure is possible with Control of high blood pressure is possible with lifestyle change and medicationlifestyle change and medication

LipidsLipids

High level of LDL-cholesterol and other High level of LDL-cholesterol and other abnormal lipids are important risk factors abnormal lipids are important risk factors for CVDfor CVD

Cholesterol is transported in two kinds of Cholesterol is transported in two kinds of lipoproteins: LDL and HDLlipoproteins: LDL and HDL

LDL can lead to increasing the risk of heart attack LDL can lead to increasing the risk of heart attack and ischaemic strokeand ischaemic stroke

HDL reduces the risk of CHDHDL reduces the risk of CHD

Female sex hormone tends to raise HDL levelsFemale sex hormone tends to raise HDL levels

TobaccoTobacco

First evidence in 1940First evidence in 1940Higher risk among those who started Higher risk among those who started smoking before of 16smoking before of 16Passive smoking is also an risk for CHDPassive smoking is also an risk for CHDPromote CHD via:Promote CHD via: Damages the endotheliumDamages the endothelium Increases cholesterol plaquesIncreases cholesterol plaques Increase clottingIncrease clotting Raises LDL and lowers HDLRaises LDL and lowers HDL

Physical inactivityPhysical inactivity

>60% of the global population are not >60% of the global population are not sufficiently activesufficiently active

Sufficient physical activity:Sufficient physical activity: Doing more than 150 minutes of moderate Doing more than 150 minutes of moderate

physical activity or 60 minutes of vigorous physical activity or 60 minutes of vigorous physical activity a weekphysical activity a week

It can reduce the risk of CHD by 30%It can reduce the risk of CHD by 30%

ObesityObesity

Body mass index (BMI) is commonly used Body mass index (BMI) is commonly used for classifying overweight and obestiyfor classifying overweight and obestiy

In general, BMI>25 = overweight and In general, BMI>25 = overweight and BMI>30 = obeseBMI>30 = obese

Diabetes and CHD increase with increase Diabetes and CHD increase with increase in the value of BMIin the value of BMI

PreventionPreventionPersonal choices and actionPersonal choices and action

Take moderate physical activity for a total of 30 Take moderate physical activity for a total of 30 minutes on most days of the weekminutes on most days of the weekAvoid tobacco use and exposure to environment Avoid tobacco use and exposure to environment smoke, make plans to quit if you already smokesmoke, make plans to quit if you already smokeChoose a diet rich in fruits, vegetables and Choose a diet rich in fruits, vegetables and potassium, and avoid saturated fats and calorie-potassium, and avoid saturated fats and calorie-dense mealsdense mealsMaintain a normal body weight, if you are Maintain a normal body weight, if you are overweight, loss weight by increasing physical overweight, loss weight by increasing physical activity and reducing calorie intakeactivity and reducing calorie intakeReduce stress at home and at workReduce stress at home and at work

PreventionPreventionPopulation and systems Population and systems

approachesapproachesThere is a gap between what is known and what There is a gap between what is known and what is done in practiceis done in practice

Governments have a fundemental responsibilityGovernments have a fundemental responsibility

Mininstries of health can play various roles:Mininstries of health can play various roles: Making data availableMaking data available Educating the publicEducating the public Making treatment affordable and availableMaking treatment affordable and available Advocating for policy and environmental changeAdvocating for policy and environmental change

FutureFuture

Important fact:Important fact:

1.1. The global epidemic of CVD is not only The global epidemic of CVD is not only increasing, but also shifting from increasing, but also shifting from developed to developing countriesdeveloped to developing countries

2.2. Any major reduction in deaths and Any major reduction in deaths and disabilities from CVD will come from disabilities from CVD will come from prevention not cureprevention not cure