Community Medicine Department

Faculty of Medicine University of Indonesia

SETYAWATI BUDININGSIH, RETNO ASTI WERDHANI

NURI PURWITO ADI

April 4th 2012

DESCRIPTIVE EPIDEMIOLOGY

IncidencePrevalence

Holistic Diagnosis(BIOPSYCHOSOSIAL)

Risk Factors

Diagnostic Tools

ANALYTIC EPIDEMIOLOGY

Therapy, PrognosisCLINICAL EPIDEMIOLOGY(Prognostic Study, Clinical

Trial, Meta Analysis)

Triad EpidemiologyHost – Agent - Environment

Cardiovascular disease is caused by disorders

of the heart and blood vessels, and includes

coronary heart disease (heart attacks),

cerebrovascular disease (stroke), raised

blood pressure (hypertension), peripheral

artery disease, rheumatic heart disease,

congenital heart disease and heart failure.

The major causes of cardiovascular disease

are tobacco use, physical inactivity, and an

unhealthy diet.

Predispose factors :

Age, Gender, Family history, Behavior,

Sanitation, etc

Clinical Risk factors :

Obesity/Malnourished, Hypertension

Dyslipidemia, Impairment of Glucose Control,

and Systemic Inflammation, etc

Smoking raises risk of atherosclerotic disease

and potentiates myocardial infarction (MI)

Smoking cessation reduces the risk of MI and

mortality by 36%

Smoking cessation : education about the danger

of smoking and intervention with nicotine

replacement and bupropion

Relapse rate are high in the absence of

education and encouragement.

Hypertension

Atherosclerotic Coronary Heart Disease and

Peripheral Vascular Disease

Congestive Heart Failure

Congenital Heart Disease

Valvular Health Disease

Cardiac Arrhythmias

SKRT 2001

6 % HTN at 25-34 yr

15 % HTN at 35-44 yr

43 % HTN at > 55 yr

2/3 uncontrolled HTN patients at > 60 yr will have

CHD, MCI, or Stroke within 5 year

Risk of HTN is regulated by genetic background

and environmental factors

For every 20/10 mmHg increase BP above

115/75 mmHg, risk of CVD doubles (Chobanian

et al, 2003)

Prevalensi hipertensi pada penduduk umur 18

tahun ke atas di Indonesia adalah sebesar

31.7 %

Angka kejadian stroke di Indonesia adalah 8.3

per 1000 penduduk

JAMA. 1990;263:1795-1801

The reduction of BP, reduces risk of acute

cardiovascular events, progression of

atherosclerosis, and end organ injury

5 mmHg SBP reduction reduces 14 % stroke death

and 9 % CVD death (Chobanian et al, 2003)

2 mmHg DBP reduction has benefit for prevention

(Cook NR, 1996)

Atherosclerosis begins in childhood and evolves over decades (Freedman et al, 1988), affecting > 85% adults > 50yr old (Tuzcu et al, 2001)

Causes Coronary Artery Disease (CAD) and Peripheral Vascular Disease (PVD)

Risk factors : Dyslipidemia, Hypertension, Impairment of Glucose Control, Age, family history, smoking, obesity, and systemic inflammation

High HDL level reduce the risk of developing CAD

(Toth, 2001)

Patients with familial low HDL have increase risk of

premature CAD (Toth, 2003)

Patients with familial high HDL are relatively

resistant to CAD (Toth, 2004)

The more elevated level of HDL, the lower the risk

for CAD

Risk factors for CAD

Negative : HDL > 60 mg/dl

Positive :

Cigarette smoking

HDL < 40 mg/dl (men), < 50 mg/dl (women)

BP > 140 / > 90 (or use of antihypertensive agents)

Family history of premature CAD (CAD in male first

degree relative < 55 yr; CAD in female first degree

relative < 65yr)

Age (men >=45 yr; women >=55 yr)

Risk Assessment Tool for Estimating 10-year Risk of Developing Hard Coronary Heart Disease (Myocardial Infarction and Coronary Death)

The risk assessment tool below uses recent data from the Framingham Heart Study to estimate 10-year risk for “hard” coronary heart disease outcomes (myocardial infarction and coronary death). This tool is designed to estimate risk in adults aged 20 and older who do not have heart disease or diabetes. Use the calculator below to estimate 10-year risk.

Age: years

Gender: Female Male

Total Cholesterol: mg/dL

HDL Cholesterol: mg/dL

Smoker: No Yes

Systolic Blood Pressure: mm/Hg

Currently on any medication to treat high blood pressure. No Yes

35

46

190

110

Calculate 10-Year Risk

CVDDiabetes

Hypertension

DyslipidemiaLow HDL, high TG

Hyperglycemia

HypercoagulabilityImpaired fibrinolysis

Endothelialdysfunction

Change in Adipose hormones

Birth size,Childhood

growth

Hyperuricemia

Systemicinflammation

Socioeconomicstatus

PhysicalInactivity

Geneticpredisposition

Diet

Abdominal obesity,Ectopic fat deposition

InsulinResistance

The Metabolic Syndrome

Textbook of Family Medicine, Rakel, 07

The incidence of Metabolic Syndrome increases in

men and women as a function of age (Ford et al

2002, Alexander et al 2003)

Patients with Metabolic Syndrome had 3.77 fold

increase in risk of CVD mortality compared to

patients without it (Lakka et al 2002)

Patients who have ANY THREE (3) of five risk factors meet criteria for the metabolic syndrome

Risk Factor Defining Level

Abdominal obesity Men : Waist > 90 cm

Women : Waist > 80 cm

Triglycerides >=150 mg/dl

HDL Men : < 40 mg/dl

Women : < 50 mg/dl

Blood Pressure >=130 / >=85 mmHg

Fasting Glucose >=100 mg/dl

A clinical syndrome resulting from the inability

of the heart to meet metabolic requirements of

the body at normal filling measure

Patient with CHF should have their CVD risk

factors controlled aggressively

Target BP for CHF patients <130/<80 mmHg

Target BP for CHF patients WITH DM <125/<85

mmHg

An illness of children and adolescents with the

average age of onset 8-10 yr

Associated with pharyngitis, caries dentis (bad oral

hygiene), poverty, crowded living conditions, and

difference in access to or utilization of medical care

Nepal : High rates of RHD may not relate to

increased prevalence of streptococcal infection,

but to inadequate antibiotic therapy (proper

dosage and duration) of streptococcal

pharyngitis.

Philippines: giving penicillin to school children

with pharyngitis (prior to confirmation of its

etiology), can reduce the attack rate of

rheumatic fever by ten folds.

Patients with established cardiac complications

must be regularly followed-up.

This requires cooperation and understanding of

prognosis by patients and relatives and

counseling on the doctors‘ part

• Ventricular Septal Defect

• Atrial Septal Defect

• Tetralogy Fallot

• Pulmonary Stenosis

• Patent Ductus Arteriosus

• Idiopathic Pulmonary Artery Dilatation

• Dextrocardia

• Hipertensi Pulmonal Primum.

• Lain-lain

Only 1% of the children with congenital heart disease are today properly treated in Indonesia.

The lack of the information and education on the part of the patients

Uneven distribution of doctors

A shortage of pediatrician

A shortage of funding, both privately and publicly

Number of cardiac surgery hospital

**Resource: WHO and World Bank 2005

CARDIO-VASCULARDISEASES

CANCER

CHRONICRESPIRATORY

DISEASE

DIABETES

17.528.000

7.586.000

4.057.000

1.125.000

MALARIA

TUBER-CULOSISHIV/AIDS

2.830.000

WHO Statistics 2007

Age-standardized CVD mortality rate per 100.000

population (2002)

0 100 200 300 400 500

United States

United Kingdom

India

Jepang

Indonesia

Filipina

Vietnam

Timor Leste

CO

UN

TR

IES

MORTALITY RATE

mortality

Thailand

Singapore

Malaysia

China

Srilanka

Australia

Canada

WHO Statistics 2007

441

171

336

274

361

291

106

314

428

140

182

141

188

318

199

HOST :Characteristic :

Age, Gender, Behavior,

etc

ENVIRONMENT :Family, Occupation,

Housing, Sanitation, etc

AGENT :Lipid, Glucose, Bacterial, etc

DISEASE OCCURANCE : TRIAD EPIDEMIOLOGY

Pharmacology

Drugs

Non Pharmacology

(health education/ counseling) on :

Diet, Exercise, Smoking Cessation,

Drug’s compliance

IndividualPerceptions

Perceived susceptibility/

Severity of disease

Cues to action :Education,

Symptom, illnessMedia Information

Perceived threatof disease

Age, gender, ethnicity,Personality,

Socioeconomics,Knowledge

Modifying Factors

Likelihood ofBehavior change

Perceived benefitsMinus perceived

Barriers to behaviorchange

Likelihoodof Action

Health Behavior and Health Education, Glanz et al, 1997

Risk Factors

•Modifiable• Diet• Physical activity• Tobacco• Alcohol

•Non-modifiable• Age• Genetic

Risk Factors

•Modifiable• High lipids• High Blood. Pressure.

• High Blood. Glucose.

• Obesity• Malnourished

CARDIO -VASCULAR DISEASE’sOccurance

Promotion PreventionSurveillance andEarly Treatment

Social Determinants(Culture, Economy,

Finance)

Promotion and Prevention

A man, 58 years old, sees his family doctor because of chest pain. He had been well until 2 weeks ago, when he noticed tightness in the center of his chest when he was walking uphill.

Remember Risk Factors (Biopsychosocial)

58

Died 60

of CVD

Died ?

of DM

Due to lots of contributing factors and broad-

integrated disease management :

Continuing care and monitoring are important

to provide good health services for

cardiovascular disease

Educational approach and family participation

are needed for :

Patient to cope with the disease

Getting patient and family’s independence

for improving/maintaining health status

Menanggulangi kemiskinan dan kelaparan

Mencapai pendidikan dasar untuk semua

Mendorong kesetaraan gender dan pemberdayaan

perempuan

Menurunkan angka kematian anak

Meningkatkan kesehatan ibu

Memerangi HIV/AIDS, malaria, dan penyakit

menular lainnya

Memastikan kelestarian lingkungan hidup

Riskesdas 2007

Profil Kesehatan Indonesia 2005

www. americanheart.org

Toth PP, et al: Cardiovascular Disease. In: Rakel RE, et all (ed): Textbook of Family Medicine, 7th ed. Philadelphia, Saunders Elsevier, 2007:735-805

Branch WT, et al (ed): Cardiology in Primary Care, Intl ed. New York, McGraw-Hill, 2000

Fletcher RH, et al: Clinical Epidemiology the essentials, 2nd ed. Baltimore,Williams & Wilkins, 1988

Glanz K, et al: Health Behavior and Health Education, 2nd ed. San Francisco, Jossey-Bass Publishers, 1997

Affandi M. Penyakit Jantung Bawaan: Apa yang harus dilakukan?. Cermin Dunia Kedokteran no 31

A Ibrahim, et all. Rheumatic Heart Disease: How Big is the Problem?. Med J Malaysia vol 50 no 2 June 1995

Balaban DJ: Epidemiology and Prevention of Selected Chronic Illnesses. In: Cassens BJ (ed): Preventive Medicine and Public Health, 2nd ed. Philadelphia, Harwal Publishing,1992:135-138