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 DiseaseGlobal Burden of Cardiovascular Disease

Developing countries• 80% of worldwide CV deaths• Occur at a younger age• 2010 – 70% of the elderly will

live in the developing world

Total deaths – 57 million

CardiovascularCardiovascular

16.7 million

HIVTB

Malaria

HIVTB

Malaria

5 million

Lopez. Lancet 2006; Reddy. NEJM 2004Lopez. Lancet 2006; Reddy. NEJM 2004

2002 statistics

International Comparison

170

183

212

289

413

557

714

1555

0 200 400 600 800 1000 1200 1400 1600

Japan

France

Canada

USA

Rural China

Poland

Hungary

Russia

CVD Death Rates/100,000 (Men ages 35-74)

Cardiovascular Disease in the Americas

Highest

Lowest

Life Expectancy in the Americas

• 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

• 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 and risk factors

Rheumatic heart disease, infections, nutritional cardiomyopathies

Regional examples Sub-Saharan Africa, rural India, Haiti

Stage 1: Haiti

Life expectancy = 55 years

Causes of Death Haiti 2002Cause of Death Deaths YLL

HIV/AIDS 22% 20%

Lower respiratory infections 7% 9%

Cerebrovascular disease 6% 3%

Meningitis 5% 7%

Diarrheal diseases 5% 7%

Perinatal conditions 4% 7%

Tuberculosis 4% 4%

Hypertensive heart disease 3% 1%

Anemia 3% 4%

Diabetes mellitus 3% 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 2002Cause of Death Deaths YLL

Lower respiratory infections 9% 12%

Perinatal conditions 8% 14%

Diarrheal diseases 6% 10%

Ischemic heart disease 5% 2%

Cerebrovascular disease 4% 2%

Tuberculosis 4% 4%

Cirrhosis of the liver 3% 2%

Nephritis and nephrosis 3% 2%

Cervix and uterine cancers* 2% 2%

Diabetes mellitus 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 2002Cause 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 4% 4%

HIV/AIDS 4% 9%

Stomach cancer 3% 2%

Nephritis and nephrosis 3% 3%

Perinatal conditions 2% 8%

Breast cancer 2% 3%

Yang. Lancet, 2008Yang. Lancet, 2008

0

20

40

60

80

100

1973 2005

Changing Distribution of the Causes ofDeath in Peoples Republic of China

Changing Distribution of the Causes ofDeath in Peoples Republic of China

Pro

po

rtio

n o

f d

eath

s (%

)P

rop

ort

ion

of

dea

ths

(%)

YearYear

Unknown

Injury

Other non-communicable diseases

Chronic obstructive pulmonary disease

Cerebro-cardiovascular disease

Cancer

Maternal and perinatal conditions

Communicable diseases

Unknown

Injury

Other non-communicable diseases

Chronic obstructive pulmonary disease

Cerebro-cardiovascular disease

Cancer

Maternal and perinatal conditions

Communicable diseases

Stage 4: Age of Delayed Degenerative Diseases

Life expectancy > 75 years

CVD deaths 50% of total deaths

Prominent CV diseases and risk factors

Stroke and ischemic heart disease at old age

Regional examples

Western Europe, Australia and New Zealand, North America, USA

Causes of Death USA 2002Cause 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 4% 1%

Diabetes mellitus 3% 3%

Colon and rectum cancers 3% 3%

Lower respiratory infections 3% 2%

Breast cancer 2% 2%

Road traffic accidents 2% 6%

Age-adjusted US CVD Disease Trends

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

Years1996-2004

Hospital discharges for cardiovascular diseases. Hospital discharges for cardiovascular diseases. (United States: 1970-2006). Note: Hospital discharges (United States: 1970-2006). Note: Hospital discharges include people discharged alive, dead and status include people discharged alive, dead and status unknown. unknown. Source: NCHS and NHLBI.Source: NCHS and NHLBI.

0

1

2

3

4

5

6

7

70 75 80 85 90 95 00 06

Years

Dis

ch

arg

es i

n M

illi

on

s

Estimated direct and indirect costs (in billions of dollars) Estimated direct and indirect costs (in billions of dollars) of major cardiovascular diseases and stroke of major cardiovascular diseases and stroke (United States: 2009). (United States: 2009). Source: NHLBI.Source: NHLBI.

165.4

68.9 73.4

37.2

0

40

80

120

160

200

Coronary HeartDisease

Stroke HypertensiveDisease

Heart Failure

Bil

lio

ns

of

Do

llar

s

Total Cost = 344.9 billion dollars

Transition Factors 1 → 2

Sanitation – water qualityImmunizationAntibiotics

Population growthOlder population

Increased mechanization of food productionMore processed food

Increased salt intake

HypertensionHypertensive heart diseaseHemorrhagic stroke

Transition Factors 2 → 3

Changing economyAffluenceMass media

Cigarette smokingReduced physical activityIncreased caloric intakeMore meat consumptionObesity

DiabetesHyperlipidemiaIschemic StrokeMI

Incubation Period for Chronic Disease

Transition Factors 3 → 4

More educated publicIncreased spending on medical careSecondary prevention practicesPrimary prevention practices

Improved survival from MIReduced MI, stroke at young ages

CHD Trends

McGovern et al, Circulation 2001;104:19-24

Reduction in CVD Death Rate in US

Pre-1985 due largely to lifestyle changes

• Smoking cessation59% 25%

• Decreased dietary fat intake

• Increased leisure-time physical activity

Post-1985 due largely to medical management

• Coronary care units

• Electrical defibrillators

• Thrombolysis

• Emergent angioplasty

• Medical Rx– Aspirin, beta-blockers,

ACE-inhibitors, statins

McGovern et al. Circulation 2001;104:19-24

[Primary Prevention] [Secondary Prevention]

CAD Prevalence in Patients Who Died of Unnatural Causes in Olmsted County, MN and Had Autopsy Nemetz et al. Arch Intern Med

2008;168:264-270

Causes of Death Honduras versus USWhere is Honduras in the Epidemiologic Transition?

Source: Death and Daly estimates by cause, 2002http://www.who.int/entity/healthinfo/statistics/bodfbddeathdalyestimates.xls

Causes of Death Honduras 2002Cause of Death Deaths YLL

Ischemic heart disease 11% 4%

HIV/AIDS 9% 14%

Perinatal conditions 7% 13%

Cerebrovascular disease 5% 3%

Diabetes mellitus 4% 2%

Diarrheal diseases 4% 7%

Lower respiratory infections 4% 5%

Nephritis and nephrosis 4% 2%

Hypertensive heart disease 3% 1%

Protein-energy malnutrition 3% 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 = 61US: 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 2008Financial 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 man-made 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

$26,000 USD $5,000 USD$93,000 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?