„Cardiovascular disease has the same meaning for health care today as the epidemics of centuries had for medicine in earlier times: 50% of the population in developed countries die of cardiovascular disease” (Pál Kertai) .Someone has a heart attack every two minutes (British Heart Foundation)
Public Health Significance:
Leading cause of mortality in developed countries and a rising tendency in developing countries (disease of civilization)
A major impact on life expectancy
Significantly contributes to morbidity and death rates in the middle aged population: potential life years lost, common cause of premature death, labor force (economic costs), family life
Morbidity: nearly 30% of all disability cases
Contributes to deterioration of the quality of life
Types of Cardiovascular Disease:
Coronary heart disease (CHD, ischemic heart disease, heart attack, myocardial infarction, angina pectoris)
Cerebrovascular disease (stroke, TIA, transient ischemic attack)
Hypertensive heart disease
Peripheral vascular disease
Heart failure
Rheumatic heart disease (streptococcal infection)
Congenital heart disease
Cardiomyopathies
Tasks of Cardiovascular Epidemiology:
Detection of the occurrence and distribution of CVD in populations, surveillance, monitoring, trends of changesStudy of the natural history of CVD
Formulation and testing of etiological hypotheses (risk factors)
Contribution to the development of cardiovascular prevention programs and the measurement of their effectiveness
Parts of Cardiovascular Epidemiology:
1. Descriptive epidemiology:
Describing distribution of cardiovascular disease by means of certain characteristics such as : PERSON (i.e., age, gender, ethnicity) TIME and PLACE
2. Analytic epidemiology:
Analyzing relationships between CVD and risk factors (which elevate the probability of a disease at population level), risk model and multicausal developments
3.Experimental epidemiology/Interventions:
Strategies of cardiovascular prevention (primordial, primary, secondary, tertiary; individual and community levels)
Descriptive Epidemiology I. Distribution Patterns in the World
In the world: CVD deaths account for one third of all deaths (25-50% depending on the level of economic development) among which 50%: coronary deaths
CVD made up 16.7 million of global deaths in 2002, among which 7 million due to coronary heart disease, 6 million due to stroke
Distribution of types of CVD in global deaths :
-Global cardiovascular deaths in 2002: 16.7 million
-among which: coronary heart disease 7.2 million > stroke 6.0 million > 0.9 million hypertensive heart disease > 0.4 million inflammatory heart disease > 0.3 million rheumatic heart disease > 1.9 million other CVD
II. AGE
Early lesions of blood vessel, atherosclerotic plaques: around 20 years - adult lifestyle patterns usually start in childhood and youth (smoking, dietary habits, sporting behavior, etc.)
Increase in CVD morbidity and mortality: in age-group of 30-44 years
Premature death (<64 years of age, or 25-64 years): in the elderly population more difficult to interpret death rate due to multiple ill health causes
III. GENDER:
Widespread idea: CVD is often thought to be a disease of middle-aged men.
Cardiovascular mortality (fatal cases) are more common among men. However, CVD affect nearly as many women as men, albeit at an older age
Women: special case (WHO, 2004)
a.Higher risk in women than men (smoking, high triglyceride levels)
b.Higher prevalence of certain risk factors in women (diabetes mellitus, depression)
c. Gender-specific risk factors (risks for women only) (oral contraceptives, hormone replacement therapy, polycystic ovary syndrome)
IV. TIME and PLACE
SDR: Standardized Death Rate
Direct mode of standardization, using the age distribution of a hypothetical European standard population
Premature death rates for comparison purposes (<64 years of age)
V. World Trends
Developed countries: decreasing tendencies (e.g, USA: 30% between 1988-98, Sweden: 42%)
improvement of lifestyle factors, for example, a decrease of smoking and a higher level of health consciousness in many developed countries
better diagnostic and therapeutic procedures (e.g., bypass surgeries, hypertension screening, pharmacological treatment of hypertension and hypercholesterinaemia, access to health care)
Developing countries: increasing tendencies
increasing longevity, urbanization, and western type lifestyle
Analytic Epidemiology I.Role of Risk Factors:
Over 300 risk factors have been associated with coronary heart disease, hypertension and stroke
Approx. 75% of CVD can be attributed to conventional risk factors
Risk factors of great public health significance:
- high prevalence in many populations
- great independent impact on CVD risk
- their control and treatment result in reduced CVD risk
- Developing countries: double burden of risks (problems of undernutrition and infections + CVD risks)
Classification of Risk Factors
Major modifiable risk factors
High blood pressure
Abnormal blood lipids
Tobacco use
Physical inactivity
Obesity
Unhealthy diet
Diabetes mellitus
Other modifiable risk factors
Low socioeconomic status
Mental ill health (depression)
Psychosocial stress
Heavy alcohol use
Use of certain medication
Lipoprotein(a)
Non-modifiable risk factors
Age
Heredity or family history
Gender
Ethnicity or race
”Novel” risk factors
Excess homocysteine in blood
Inflammatory markers
(C-reactive protein)
Abnormal blood coagulation
(elevated blood levels of fibrinogen)
II. Hypertension:
Systolic blood pressure >140 Hgmm and/or a diastolic blood pressure > 90 Hgmm
Free of clinical symptoms for many years (screening)
In most countries, up to 30 percent of adults suffering, increasing with age in civilized countries
Positive family history
Dietary habits (a high intake of salt, processed food, low levels of water hardness, high thyramine content of food, alcohol use)
Modern lifestyle (increased sympathetic activity, psychosocial stress, leading position in job)
III. Rheumatic Fever and Rheumatic Heart Disease
Development: Rheumatic fever usually follows an untreated beta-haemolytic streptococcal throat infection in children
As a consequence, the heart valves are permanently damaged which may progress to heart failure
Today mostly affects children in developing countries, linked to poverty, inadequacy of health care access
Occurrence: 12 million people currently affected by rheumatic fever and RHD, two-thirds are children (5-15 years), for example: approx. 1 000 000 in Sub-Saharan Africa, 700 000 in South-Central Asia, 176 000 in China, 150 000 in North Africa, 40 000 in Eastern Europe (!)
IV. Abnormal Blood Lipids:
Serum cholesterol: structure and functioning of blood vessels, atherosclerotic plaques
Altering functions of cholesterol fractions (LDL: risk, HDL: protection)
Estrogen: tends to raise HDL-cholesterol and lower LDL-cholesterol, protection for women in reproductive age
Partially genetic determination of metabolism, partially dependent of nutrition (egg, meats, dairy products)
V. Tobacco Use:
The link between smoking and CVD (mainly CHD) was identified in 1940
Greatest risk: initiation < 16 years
Passive smoking: additional risk
Women smokers: are at higher risk of CHD and CVD than male smokers
Several mechanisms: damages the endothelium lining, increases atherosclerotic plaques, raises LDL and lowers HDL, promotes artery spasms, raises oxigen demand of the heart muscle
- Nicotine accelerates the heart rate (RR), and raises blood pressure
VI. Physical Inactivity:
Regular physical activity: protective factor
Intensity and duration (15 minutes/week intermediate or 60 minutes/week heavy)
Modernization, urbanization, mechanized transport: sedentary lifestyle (60% of global population)Raises CVD risk and also the development of other risk factors (glucose metabolism, diabetes mellitus, blood coagulation, obesity, high blood pressure, worsening lipid profile)
Physical activity: helps reduce stress, anxiety and depression
VII. Obesity, Diabetes Mellitus, Unhealthy Diet:
Body Mass Index: > 25: overweight, > 30: obesity
A modern ”epidemic”: More than 60% of adults in the US are overweight or obese, in China: 70 million overweight people
Elevates the risk of both CVD and diabetes mellitus
Diabetes mellitus: damages both peripheral and coronary blood vessels
Unhealthy diet: low fruit and vegetable, fiber content, and high saturated fat intake, refined sugar
VIII. Psychological and social factors:
Psychological factors (Type A behavior, hostility)
Depression and CVD: bidirectional link
a. depression may increase the risk of CVD and worsen recovery process
b. CVD may induce depression
Low socioeconomic status (SES):
a.in developed countries: less educated and lower SES groups (accumulation of risk factors)
b. in developing countries: more educated and higher SES groups (western lifestyle)
Cardiovascular Prevention:
Primordial: Social, legal and other (often nonmedical) activities which may lead to a lowering of risk factors (e.g., socioeconomic development, smoke-free restaurants)
Primary: Controlling risk factors contributing to CVD (health education programs, anti-smoking campaign, sports programs, nutrition counselling, regular check of blood pressure and certain blood parameters, e.g., cholesterol, blood lipids, glucose)
Secondary: Screening and treatment of symptomatic patients, set up personal risk profile
Tertiary: Cardiovascular rehabilitation, prevention of recurrence of CVD (new heart attack: 5-7 times higher risk among CVD patients)
The individual approach (detecting those at greatest risk): lifestyle guidelines (e.g., smoking cessation)
The population-wide approach: (the whole population, western lifestyle )
Example for community-wide CV prevention programs:
- Framingham Heart Study (1948-) Framingham Risk Scoring
- North-Karelia Project (1972-) Finland
- Stanford Projects (1972-75, 1980-86) USA
- Minnesota Cardiovascular Health Program (1980-88) USA
- Multiple Risk factor Intervention Trial (1972-79) USA