- 1. Cardiovascular Epidemiology: Definitions Historical
Perspectives and Assessing Risk of CVD Recent trends and population
differences in CHD and CHD risk factors
2. ATotal CVD BCancer CAccidents DChronic Lower Respiratory
Diseases EDiabetes Mellitus FAlzheimers Disease CVD and other major
causes of death for all males and females(United States:
2005).Source: NCHS. 3. Percent of Total DeathsATotal CVD BCancer
CAccidents DChronic Lower Respiratory Diseases EDiabetes Mellitus
FAlzheimers Disease CVD and other major causes of death for white
males and females(United States: 2005).Source: NCHS. 4. Percentage
breakdown of deaths from cardiovascular diseases(United States:
2006 preliminary)* - Not a true underlying cause.Source: NCHS and
NHLBI.Heart Failure* 5. Age-adjusted death rates for CHD, stroke,
lung and breast cancer for white and black females(United States:
2005). Source: NCHS and NHLBI. 6. CVD deaths vs. cancer deaths by
age. (United States: 2005).Source: NCHS and NHLBI. 7. Deaths from
cardiovascular disease (United States: 19002006
preliminary).Source: NCHS and NHLBI. 8. CVD diseasemortalitytrends
for males and females (United States: 1979-2005).S ource: NCHS and
NHLBI.Note: No comparability ratios were applied 9. Hospital
discharges for cardiovascular diseases.(United States:
1970-2006).Note: Hospital discharges include people discharged
alive, dead and status unknown.Source: NCHS and NHLBI. 10. Trends
in Cardiovascular Operations and Procedures(United States:
1979-2005) .Source: NCHS and NHLBI. Note: Inpatient procedures
only. 11. Estimated direct and indirect costs (in billions of
dollars) of major cardiovascular diseases and stroke(United States:
2008).Source: NHLBI. 12. Development of Atherosclerotic Plaques
Normal Fatty streak Foam cells Lipid-rich plaque Lipid core Fibrous
cap Thrombus Ross R.Nature.1993;362:801-809. 13. PDAY: Percentage
of Right Coronary Artery Intimal Surface Affected With Early
Atherosclerosis PDAY= Pathobiological Determinants of
Atherosclerosis in Youth. Strong JP, et al.JAMA .
1999;281:727-735.Fatty streaks Raised lesions White 15-19 20-24
25-29 30-34 0 10 20 30 Women 0 10 20 30 15-19 20-24 25-29 30-34
Black Age (y) 0 10 20 30 White 15-19 20-24 25-29 30-34 Men Black
Intimal surface (%) 15-19 20-24 25-29 30-34 0 10 20 30 14. Most
Myocardial Infarctions Are Caused by Low-Grade Stenoses
-
- Pooled data from 4 studies: Ambrose et al, 1988; Little et al,
1988; Nobuyoshi et al, 1991; and Giroud et al, 1992. (Adapted from
Falk et al.)
-
- Falk E et al,Circulation , 1995.
15. Coronary Remodeling (Adapted from Glagov et al.) Normal
vessel Minimal CAD Progression Compensatory expansion maintains
constant lumen Expansion overcome: lumen narrows Severe CAD
Moderate CAD Glagov et al,N Engl J Med , 1987. 16. Atherosclerotic
Plaque Rupture and Thrombus Formation Intraluminal thrombus Growth
of thrombus Intraplaque thrombus Lipid pool Blood Flow Adapted from
Weissberg PL.Eur Heart J Supplements1999:1:T1318 17. Features of a
RupturedAtherosclerotic Plaque
- Prior luminal obstruction < 50%
- Visible ruptureand thrombus
Constantinides P.Am J Cardiol. 1990;66:37G-40G. 18. Vulnerable
Versus StableAtherosclerotic Plaques Libby
P.Circulation.1995;91:2844-2850. Vulnerable Plaque
- Inflammatory cell infiltrates:
Lumen Lipid Core Fibrous Cap
- Smooth muscle cells:more extracellular matrix
Stable Plaque Lumen Lipid Core Fibrous Cap 19. Correlation of CT
angiography of the coronary arteries with intravascular ultrasound
illustrates the ability of MDCT to demonstrate calcified and
non-calcified coronary plaques (Becker et al., Eur J Radiol 2000)
Non-calcified, soft, lipid-rich plaque in left anterior descending
artery (arrow) (Somatom Sensation 4, 120 ml Imeron 400). The plaque
was confirmed by intravascular ultrasound (Kopp et al., Radiology
2004) 20. Clinical Manifestationsof Atherosclerosis
-
-
- Stable angina, acute myocardial infarction, sudden death,
unstable angina
-
- Peripheral arterial disease
-
-
- Intermittent claudication, increased risk of death from heart
attack and stroke
American Heart Association, 2000. 21. Definitions
- CORONARY ARTERY DISEASE (CAD) or CORONARY HEART DISEASE (CHD)
(often broadly referred to as ISCHEMIC HEART DISEASE (IHD):
primarily myocardial infarction and sudden coronary death, broader
definition may include angina pectoris, atherosclerosis, positive
angiogram, and revascularization (perceutaneous coronary
interventions, or PCI such as angioplasty and stents)
- CARDIOVASCULAR DISEASE or CVD includes CHD, cerebrovascular
disease, peripheral vascular disease, and other cardiac conditions
(congenital, arrhythmias, and congestive heart failure)
22. Definitions (cont.)
- SURROGATE MEASURES include: carotid intimal medial thickness
(IMT), coronary calcium, angiographic stenosis, brachial ultrasound
flow mediated dilatation (FMD)
- Hard endpoints include myocardial infarction, CHD death, and
stroke
23. Prevalence (%) of Coronary Calcium: US Adults Ages 45-84
Years(The MESA Study). Source: Bild et al., Circulation.
2005;111:1313-1320. 24. Prevalence of stroke by age and sex(NHANES:
2005-2006).Source: NCHS and NHLBI. 25. Annual age-adjusted
incidence of first-ever stroke, by race.Inpatient plus
out-of-hospital ascertainment.(GCNKSS: 1993-94 and 1999).Source:
Stroke 2006;37;2473-2478. 26. Prevalence of heart failure by age
and sex(NHANES: 2005-2006).Source: NCHS and NHLBI. 27. Note:
Hospital discharges include people discharged alive, dead and
status unknown. Hospital discharges for heart failure by sex.
(United States: 1979-2006).Source: NHDS/NCHS and NHLBI. 28. 29.
Lifetime Risk of Coronary Heart Disease in the Framingham Study
At age 40 years: 48.6% 31.7% At age 70 years: 34.9% 24.2%
Lloyd-Jones et al.Lancet 1999;
353:89-92____________________________________________________________
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30. First Coronary Events: Framingham Study
- Percent as Specified Event
- Infarction Pectoris Death
- Age Men WomenMen WomenMen Women
- 35-6443% 28% 41%59% 9% 4%
- 65-84 55% 44% 28%41% 11% 7.4%
- Framingham Study 44 year follow-up.
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____________________________________________________________ 31.
Estimated 10-Year CHD Risk in55-Year-Old Adults According to
Levelsof Various Risk Factors Framingham Heart Study A B C D Blood
Pressure (mm Hg) 120/80 140/90 140/90 140/90 Total Cholesterol
(mg/dL) 200 240 240 240 HDL Cholesterol (mg/dL) 50 50 40 40
Diabetes No No Yes Yes Cigarettes No No No Yes mm Hg = millimeters
of mercury mg/dL= milligrams per deciliter of blood Source:
Circulation 1998;97:1837-1847. 32. Estimated 10-Year Stroke Risk in
55-Year-Old Adults According to Levels of Various Risk
FactorsFramingham Heart Study A B C D E F Systolic BP* 95-105
130-148 130-148 130-148 130-148 130-148 Diabetes No No Yes Yes Yes
Yes Cigarettes No No No Yes Yes Yes Prior Atrial Fib. No No No No
YesYes Prior CVD No No No No No Yes Source: Stroke 1991;22:312-318.
*BP in millimeters of mercury (mmHg) 33. Offspring CVD Risk by
Parental CVD Status: Framingham Study Risk Ratio 2.5 2 1.5 1 0.5 0
Men Women 1.0 1.7 2.2 1.0 1.7 1.7 Adjusted for: age, total/HDL
Chol. ratio, SBP, smoking, diabetes, BMI Parental CVD
