3.epidemiological aspects of cvs_dr ayaz bhatti
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Towards the End ofTowards the End ofVascular Disease in theVascular Disease in the
2121stst CenturyCentury
Dr Muhammad Ayaz BhattiDr Muhammad Ayaz Bhatti
Department of CommunityDepartment of Community
MedicineMedicine
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Leaning objectivesLeaning objectivesLECTURE TWO
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Preventive cardiology is the branch of medical science
which deals with the prevention of cardiovascular
problems and their treatment and rehabilitation.
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PREVENTION OF CVDPREVENTION OF CVD
WHO expert committee recommended onthe prevention of CVD as follows.
A. Population Strategy.
Prevention in the whole populations.
Primordial prevention in the whole populations.
B. High Risk strategy
C. Secondary prevention
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Population Strategy.Population Strategy.
CHD a mass disease.
Approach focuses control of underlying causes (Risk
Factors) in the whole populations
The aim is to shift the whole risk factor distribution in the
direction of the biological NORMALITY.
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1.1. Dietary Changes.Dietary Changes.
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2.2. SmokingSmokingThe Goal should be smoke free societyThe Goal should be smoke free society
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3.3. Blood PressureBlood Pressure
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4.4. Physical ActivityPhysical Activity
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A.A. PRIMORDIAL PREVENTIONPRIMORDIAL PREVENTION
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1
B.B. HIGH RISK STRATEGYHIGH RISK STRATEGYi. Identifying risk groupsii. Give them advice
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C.C. SECONDARY PREVENTIONSECONDARY PREVENTION
Prevent recurrence and progression of CHD (Drug trials, coronary surgery, pacePrevent recurrence and progression of CHD (Drug trials, coronary surgery, pace
makersmakers
Principles governing secondary prevention arePrinciples governing secondary prevention are
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D.D. TERTIARY PREVENTIONTERTIARY PREVENTION
Revascularization procedures forRevascularization procedures forpatients with Angina pectoris.patients with Angina pectoris.
Coronary artery By Pass Grafting CABG
Percutaneous Transluminal Angioplasty PTCA
1
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Diet High in Elevated AtherosclerosisDiet High in Elevated AtherosclerosisAnimal Fat CholesterolAnimal Fat Cholesterol
HypertensionHypertension
DiabetesDiabetes
SmokingSmoking
PhysicalPhysical
InactivityInactivity
CausalCausal Process in AtherosclerosisProcess in Atherosclerosis
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Percent of Energy from Different Food ComponentsPercent of Energy from Different Food Components
Hunter-Hunter-
GatherersGatherersPeasantPeasant
AgriculturalistsAgriculturalistsModern AffluentModern Affluent
SocietiesSocieties
15-2015-20
50-7050-70
15-2015-20
10-1510-15
55
60-7560-75
10-1510-15
14+14+
2020
25-3025-30
1212
Salt (g/d)Salt (g/d) 11 5-155-15 1010
Fiber (g/d)Fiber (g/d) 4040 60-12060-120 2020
FatFat
SugarSugar
StarchStarch
ProteinProtein
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CHD and Fat Intake in 40 CountriesCHD and Fat Intake in 40 Countries
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CHD and Milk Intake inCHD and Milk Intake in
40 Countries40 Countries
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Serum Cholesterol and Relative RiskSerum Cholesterol and Relative Risk
of CHD, MRFITof CHD, MRFIT
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CHD = ICD-9 410-414, 429.2.
Data source: CDC Wonder
500
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The Development Process of CVDThe Development Process of CVD
Social andSocial and
EnvironmentalEnvironmental
ConditionsConditions
AdverseAdverse
BehavioralBehavioral
PatternsPatterns
MajorMajor
RiskRisk
FactorsFactors
First Event/First Event/
Sudden DeathSudden DeathDisability/Disability/
Risk ofRisk of
RecurrenceRecurrence
LateLate
DeathDeath
WholeWhole
PopulationPopulationWholeWhole
PopulationPopulationPersonsPersons
with Riskwith Risk
FactorsFactors
Cases withCases with
First Fatal orFirst Fatal or
Non-FatalNon-Fatal
EventsEvents
SurvivorsSurvivors LateLate
DeathsDeaths
Policy andPolicy andEnvironmentalEnvironmental
ChangeChange
BehaviorBehaviorChangeChange Risk FactorRisk FactorDetectionDetection
and Controland Control
EmergencyEmergencyCare/AcuteCare/Acute
CaseCase
ManagementManagement
RehabilitationRehabilitation/Long-Term/Long-Term
CareCare
End-Of-End-Of-Life CareLife Care
PathwayPathway
Target PopulationTarget Population
InterventionsInterventions
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0
10
20
30
40
50
60
70
C
HD
SBP: 142
Chol: 245
Smoking: NoSmoking: No NoNo Yes YesYes Yes
CHD among Low and High RiskCHD among Low and High Risk
Men in MRFITMen in MRFIT
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Phases of CHD Decline in the USPhases of CHD Decline in the US
Phase 1 1960-Phase 1 1960-8585
Rapid fall in mortality; SignificantRapid fall in mortality; Significantin smoking and intake of animal fat;in smoking and intake of animal fat;
Treatment of high BP.Treatment of high BP.
Phase 2 1985Phase 2 1985 2000 2000
National decline slows for all but white men;National decline slows for all but white men;Large regional/ethnic disparitiesLarge regional/ethnic disparities
emerge; Tertiary careemerge; Tertiary careplays a bigger role.plays a bigger role.
?? Phase?? Phase3 2000 153 2000 15
Decline continues for all groups; HighDecline continues for all groups; Highcholesterol now effectively treated;cholesterol now effectively treated;
Cigarette smoking drops to low levels;Cigarette smoking drops to low levels;
Dietary goals achieved; Obesity/diabetesDietary goals achieved; Obesity/diabetesepidemic reversed.epidemic reversed.
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How Can We Eliminate CHD asHow Can We Eliminate CHD as
a Mass Disease?a Mass Disease?
1.1. Eliminate smokingEliminate smoking
2.2. Reduce total fat to
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Steps to Eliminate Vascular DiseaseSteps to Eliminate Vascular Disease
1.1. CigarettesCigarettes
** taxtax
** Enforce sales lawsEnforce sales laws
** Mount vigorous anti-smokingMount vigorous anti-smokingadvertising campaignadvertising campaign
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Steps to Eliminate Vascular DiseaseSteps to Eliminate Vascular Disease
continuedcontinued
2.2. FoodFood** salt content 5% / yearsalt content 5% / year
** Regulate fast food industryRegulate fast food industry
** Promote alternate take out foodsPromote alternate take out foods
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Steps to Eliminate Vascular DiseaseSteps to Eliminate Vascular Diseasecontinuedcontinued
3.3. Obesity/ExerciseObesity/Exercise
** Take up 10% of streetsTake up 10% of streets
** Create walking and bike boulevardsCreate walking and bike boulevards
** Require employers to provideRequire employers to provide
exercise facilitiesexercise facilities** Restore PE in schoolsRestore PE in schools
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Steps to Eliminate Vascular DiseaseSteps to Eliminate Vascular Diseasecontinuedcontinued
4.4. Racial/Ethnic/SES DisparitiesRacial/Ethnic/SES Disparities
** Develop national health systemDevelop national health system
** Invest in economically depressedInvest in economically depressed
regions/neighborhoodsregions/neighborhoods
** Provide Scandinavian level socialProvide Scandinavian level socialservicesservices
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SURVEYSSURVEYS
The widely reportedThe widely reported
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The widely reportedThe widely reported
intervention trials areintervention trials are
1. FRAMINGHAM HEART STUDY2. The Stanford Heart Disease prevention
programme in California.
3. The North Kerelia Project in Finland
4. The OSLO study
5. The Multiple Risk Factor Intervention Trial
(MRFIT in USA
6. Lipid Research Clinics Study.
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FRAMINGHAM HEARTFRAMINGHAM HEART
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FRAMINGHAM HEARTFRAMINGHAM HEART
STUDYSTUDY1. 1951 one of the best known Prospective study
2. Established the nature of risk factors and their relative
importance .
3. Major risk factors were identified.
4. According to this study four main possibilities to
intervention in prevention of
5. Reduction of serum cholesterol
6. Cessation of smoking
7. Control of hypertension
8. Promotion of physical activity.
The Stanford Heart Disease preventionThe Stanford Heart Disease prevention
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The Stanford Heart Disease preventionThe Stanford Heart Disease prevention
programme in California.programme in California.
1. To determine whether community healtheducation can reduce the risk ofcardiovascular disease a field experiment wasundertaken in 1972 in three towns withpopulation varying 12000 to 15000. in two
towns intensive mass education campaignswere conducted .
2. The third community served as control3. After two years knowledge and behavior was
assessed and diet smoking, blood pressure
serum cholesterol.4. The risk was reduced in the intervention group
as compared to the Control group.
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The North Kerelia Project in FinlandThe North Kerelia Project in Finland
North Keralia is a country in the Eastern part of Finland, where
CHD is particularly common.
Its 185000 work mostly farming and forestry and live in the
countryside
A multiple risk factor intervention trial was started in 1972. The aim was
1. To reduce the high level of risk factors for CVD(smoking, blood
pressure and serum cholesterol).
2. To promote the early diagnosis, treatment and rehabilitation of
patients with CVD.
The North Kerelia Project in FinlandThe North Kerelia Project in Finland
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A control population was established in aneighbouring country which has similar CV mortality
The main strategy was employed community actionagainst risk factors and advice on their avoidance.
Follow up 5 years demonstrated a significantreduction in all three major risk factors. By 1979mortality began to decline by 24 % in men and 51%in women compared with 12% in men and 26% inrest of Finland.
The North Kerelia Project in FinlandThe North Kerelia Project in Finland
continuedcontinued
h l i l i kMRFIT th lti l Ri k F t
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MRFIT the multiple Risk FactorMRFIT the multiple Risk Factor
Intervention TrialIntervention Trial
Carried out in USA on 12866 men aged 35-57years.
Half group randomly allocated to anintervention programme being seen every 4
months to ensure adequate control of riskfactors.
The other half Control group received medicalexamination once yearly and no specific advice
was given to them.Over 7 years follow up IHD mortality reduced22% more intervention group.
OSLO DIET /SMOKINGOSLO DIET /SMOKING
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OSLO DIET /SMOKING/
INTERVENTION STUDYINTERVENTION STUDY1. Study began in 1973
2. 16202 Norwegian men age 40-49 years were screened for
CHD risk factors.
3. Of these 1232 healthy normotensive men at risk (total
cholesterol 290-379 and smoking) were selected for a 5
year randomized trial.
4. The aim of the study was to determine whether lowering of
serum lipids and cessation of smoking would reduce theincidence of first attack of CHD in males aged 40-49 years.
5. The intervention was lowering cholesterol through dietary
means (polyunsaturated fat in diet and cessation of
smoking.
6. At the end of the incidence of myocardial infarction waslower by 47% in the intervention group than in the control
group.
Th Li id R h Cli i CTh Li id R h Cli i C
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The Lipid Research Clinics CoronaryThe Lipid Research Clinics Coronary
Primary Prevention TrialPrimary Prevention Trial
Randomized, double-blind study, tested the efficacy of cholesterol
lowering in reducing risk of coronary heart disease (CHD) in 3,806
asymptomatic middle-aged American men with primary
hypercholesterolemia (type II hyperlipoproteinemia).
The treatment group received the bile acid cholestyramine resin and
the control group received a placebo for an average of 7.4 years.
Both groups followed a moderate cholesterol-lowering diet.
The treatment group had an 8.5 % and 12.5% reduction in total
cholesterol than placebo. This resulted in 24% reduction in mortality
This resulted in drug treatment of elevated serum cholesterol levels