cdc salt e-update - world heart federation...2017/11/27 · mod + vig children 12-19 yo none >0...

CDC Salt e-Update: a bi-weekly news scan –

subscribe [email protected]

mailto:[email protected]

From CVD to CVH: A Quiet Revolution---And Why It Matters

WHFEL Think Tank SeminarLima, Peru – March 23-27, 2015

Darwin R. Labarthe MD, MPH, PhD Department of Preventive Medicine

Learning objectives

• Know how the revolution changes the focus of cardiovascular theory, policy/practice, and research.

• Recognize 3 paths to the revolution and the catalytic event of February 26, 2009.

• See the impact of the revolution on cardiovascular theory, practice, and research.

4/2/2015

3

Three questions about the revolution:

• What is it?

• Where did it come from?

• Why does it matter?

4/2/2015

4

1 - What is it?

4/2/2015

5

A radical change in focus –

• health – beyond disease

• the whole population – every person, not just those at one or the other extreme

• childhood – the life course, from early on

1 - What is it?

4/2/2015

6

AHA 2020 Impact Goal“By 2020, to improve the cardiovascular

health of all Americans by 20%, while reducing deaths from cardiovascular

disease and stroke by 20%.”• 7 metrics (tobacco, physical activity, healthy

diet score, BMI, BP, total cholesterol, glucose) • 3 states (ideal, intermediate, poor)*• 2 age levels (<20, 20+)* in the absence of CV disease

Goal/Metric Poor Health Intermediate Health Ideal HealthCurrent Smoking

Adults ≥20 yo Yes Former <=12 months Never or quit >12 monthsChildren 12-19 yo Tried prior 30 days Never tried; never whole cigarette

Body Mass IndexAdults ≥20 yo ≥30 kg/m2 25-29.9 kg/m2 <25 kg/m2

Children 2-19 yo >95th percentile 85th-95th percentile <85th percentilePhysical Activity

Adults ≥20 yo None

1-149 min/wk moderate or1-74 min/wk vigorous or1-149 min/wk mod + vig

150+ min/wk moderate or 75+ min/wk vigorous or 150+ min/wk

mod + vigChildren 12-19 yo None >0 and <60 min of moderate or vigorous daily 60+ min of mod or vig daily

Healthy Diet ScoreAdults ≥20 yo 0-1 components 2-3 components 4-5 componentsChildren 5-19 yo 0-1 components 2-3 components 4-5 components

Total CholesterolAdults ≥20 yo ≥240 mg/dL 200-239 mg/dL or treated to goal <200 mg/dLChildren 6-19 yo ≥200 mg/dL 170-199 mg/dL <170 mg/dL

Blood PressureAdults ≥20 yo SBP ≥140 or DBP ≥90 mm Hg SBP120-139 or DBP 80-89 or Rx to goal <120/<80 mm Hg

Children 8-19 yo >95th percentile90th-95th percentile or SBP ≥120 or DBP ≥80

mm Hg <90th percentileFasting Plasma Glucose

Adults ≥20 yo ≥126 mg/dL 100-125 or treated to goal <100Children 12-19 yo ≥126 mg/dL 100-125 <100

The 7 CVH metrics

4/2/2015

8

1 - What is it?

4/2/2015

9





health – beyond disease

4/2/2015

10

The national goal for heart disease and stroke prevention:

- detection and treatment of risk factors

- early identification and treatment of heart attacks and strokes

- prevention of risk factors

- prevention of recurrent cardiovascular events

To improve cardiovascular health and quality of life by:

Prevention of recurrent

cardiovascular events

Early identification and treatment of heart attacks and

strokes

Detection and treatment of risk

factors

Prevention of risk factors

4 Goals of Prevention

Reducing Disability & Risk of

Recurrent CVD

Detecting & Treating Acute CVD Events

Controlling Increased CVD Risk

Preserving Low

CVD Risk

4 Lines of action

CVD PreventionCVH Promotion


Recurrent CVD



Preserving Low

CVD Risk

4 Lines of action

1 - What is it?

4/2/2015

15





1 - What is it?

4/2/2015

25





childhood – the life course, from the start

4/2/2015

26

A focus on health in the whole population has led to adoption of metrics by which to define and measure the status of CVH in bothchildren and adults.

The 3 defined strata are -ideal intermediatepoor

17.1 18.29.8

92.9

5.5 4.8 0.5

17.0

46.1

7.1

22.215.5

18.5

82.9

64.8

44.0

72.479.7 81.0

0.0

20.0

40.0

60.0

80.0

100.0

CurrentSmoking

Body MassIndex

PhysicalActivity

Healthy DietScore

TotalCholesterol

BloodPressure

FastingPlasmaGlucose

Perc

enta

ge

Poor Intermediate Ideal

Prevalence in U.S. Children

The distribution of cardiovascular health

24.533.8 31.7

76.8

15.0 17.18.2

3.2

32.9

23.2

22.9

38.441.2

30.4

72.2

33.245.2 46.6 41.7

61.4

0.0

20.0

40.0

60.0

80.0

100.0

CurrentSmoking

Body MassIndex

PhysicalActivity

Healthy DietScore

TotalCholesterol

BloodPressure

FastingPlasmaGlucose

Perc

enta

ge

Poor Intermediate Ideal

Prevalence in U.S. Adults

The distribution of cardiovascular health

Loss of CV Health Across the LifespanNHANES 2007-2008

Age Group

Per

cent

with

Idea

l CV

H M

etric

s

29

100%

0% Kids Adults

Promoting and preserving ideal cardiovascular health

intermediate CVHideal CVH poor CVH

iFavorable change in CVH

metrics (health behaviors and factors)

iUnfavorable change in CVH



intermediate CVHideal CVH poor CVH

iFavorable change in CVH


iUnfavorable change in CVH


Healthy gestation, development, and aging


1 - What is it?

4/2/2015

37

A radical change in focus – leading to a new goal of promoting and preserving cardiovascular health, from the beginning.

2 - Where did it come from?

4/2/2015

38

3 paths to the revolution –

• science – the meaning of ‘low risk’

• history – the idea of health

• myth – the view beyond the dark side

Low Risk in Long-Term Follow-Up of Chicago Cohorts (Peoples Gas, Western Electric, Chicago Heart Association Cohorts) and MRFIT Screenees - 1993

• Highly consistent associations of “favorable” values of baseline risk factors for lower CHD and all-cause death, and increased longevity.

• WE: 24-yr CHD death 69%all-cause death 42%

longevity 9 yrsMRFIT: 12-yr CHD death 89%

all-cause death 53%longevity 9+ yrs

Stamler J et al. Cardiology 1993; 82:191-222.39

Low Risk in Long-Term Follow-Up of Chicago Cohorts (Peoples Gas, Western Electric, Chicago Heart Association Cohorts) and MRFIT Screenees - 1993

• Call for “2-pronged strategy to reduce risk for the whole population” plus “special measures for very high risk people.”

• Encourage “the primary prevention of the unfavorable life-styles and life-style-related risk factors causing epidemic CHD. This is the ultimate solution…”

Stamler J et al. Cardiology 1993; 82:191-222.40

Low Risk in MRFIT and CHA Cohorts -1999

• 366,000 US individuals (~ 40,000 in Chicago)• Low risk: Serum cholesterol level <200 mg/dL SBP/DBP ≤120/80 mm Hg Not a current smoker No history of diabetes (No major ECG abnormalities)

Stamler J et al. Journal of the American Medical Association. 1999; 252(21):2012-2018.41

Risk Reduction and Life Years Gained from Low Risk Status - 1999

CVD Mortality All-Cause Mortality

Greater Life Expectancy

MRFIT men 35-39

- 85% - 50% +6.3 years

CHA men 18-39

- 80% - 57% +9.5

MRFIT men 40-57

- 76% - 55% +5.9

CHA men 40-59

- 72% - 58% +6.0

CHA women 40-59

- 73% - 40% +5.8

Stamler. Journal of the American Medical Association. 1999; 252(21):2012-2018.42

Healthy Behaviors in US Nurses• 84,129 mostly middle-aged women followed for

14 years• 5 healthy lifestyle factors Nonsmoker (never or quitter) ≥ ½ hour per day of moderate/vigorous activity BMI <25 Best 40% of dietary scores

- Low trans fat, low glycemic load, high cereal fiber, high marine ω-3 FAs, high folate, high PUFA/SFA

≥ ½ glass of wine per day (or equivalent)

Stampfer, et al. New England Journal of Medicine. 2000; 343:16-22.43

Healthy Behaviors and Risk for CHD

Risk Reduction for CHD

3 low RFs 57%

4 low RFs 66%

5 low RFs 83%

Stampfer, et al. New England Journal of Medicine. 2000; 343:16-22.44

Healthy Behaviors• Stampfer definition now associated with major

reductions in risk for CHD in US physicians over 16 years (Chiuve, Circ. 2006)

Stroke in US male physicians and femalenurses (Chiuve, Circ. 2008)

Diabetes in US nurses: 90% reduction with just favorable diet, PA and BMI (Hu, NEJM. 2001)

Diabetes in older individuals from CHS (Mozaffarian, Arch Intern Med. 2009)

45

Lifetime Risk for ASCVD by RF Strata Framingham Heart Study, Age 50

Attained Age

Adj

uste

d C

umul

ativ

e In

cide

nce

5%

36%

50%

69%

8%

27%

50%

Men Women

46%

39%

Lloyd-Jones, et al. Circulation. 2006; 113:791-798.

≥2 Major RFs1 Major RF≥1 Elevated RF≥1 Not Optimal RFOptimal RFs

46

Source: Capewell et al. WHBulletin 2010.

CH

D d

eath

s pe

r Yea

r

CH

D d

eath

s pe

r Yea

r

Coronary heart disease deaths, 2010 compared with 2000 baseline, IMPACT Model, United States.

What might lie ahead… 4 scenarios


4/2/2015

48





history – the idea of health

4/2/2015

49

1940

1950

1960

1970

1980

1990

2000

2010

1770

1 2 345

678

91011

19

131415161718

12


4/2/2015

50





4/2/2015

52

2 – Where did it come from?

4/2/2015

53

Goal

science ideal cardiovascular health

history

myth primordial prevention

Strategy


4/2/2015

54

Goal


history


Strategy


4/2/2015

55

Goal


history


Strategy

Consummation of the revolution:

4/2/2015

56

3 - Why does it matter?

4/2/2015

57

It matters because the revolution ushers in a new understanding of cardiovascular health, with greatly increased prominence of primordial prevention, and implications for –

- theory: a new conceptual model- practice: a new assessment of prevention

policy- research: a new emphasis on the life

course, from childhood on

Primordial prevention

“Real grassroots prevention should start by preserving entire risk-factor-free societies from the penetration of risk factor epidemics. Here lies the possibility of averting one of tomorrow’s world health problems. I wish to propose the term of protoprophylaxis or primordial prevention.Strasser, T. Reflections on cardiovascular diseases.Interdisciplinary Science Reviews, 1978

“The Challenge Ahead”

“The strategic key, and the greatest opportunity in preventing CVD, is to prevent the development of CVD risk in the first place.”

NHLBI, Task Force on Research in Epidemiology and Prevention of Cardiovascular Diseases, 1994 (italics added).



“The key to this challenge [to bring the CVD epidemic to an end] is the strategy of primordial prevention of the risk factors themselves…

“…as far as I know, nowhere in the world is there yet at the national level an actual policy commitment to primordial prevention of the risk factors.”

Stamler J et al. Primordial Prevention of Cardiovascular Disease Risk Factors: Panel Summary. Prev Med 29;1999:S130-S135.

4/2/2015

60

• Community prevention – 2013“Through primordial prevention , we can avert the continuing progression of CVD risk in each generation, which continues to demand remedial strategies that are too costly, too limited, and often too late.”

Pearson TA, Palaniappan LP, Artinian NT, et al. American Heart Association Guide for Improving Cardiovascular Health at the Community Level, 2013 Update. A Statement for Public Health Practitioners, Healthcare Providers and Health Policy Makers. Circulation. 2013; 127:1730-1753.


• National prevention policy – 2011

“With primordial and primary prevention, cardiovascular disease is largely preventable.

“Population-based and clinical studies highlight the importance of primordial prevention, defined herein as prevention of risk factors in the first place.”

WeintraubWS, Daniels SR, Burke LE et al. Value of Primordial and Primary Prevention for Cardiovascular Disease : A Policy Statement From the American Heart Association. Circulation published online July 25, 2011.


• Global prevention strategies - 2012

The CVD community could contribute by:

“Advocating for greatly increased focus on the prevention of risk in the first place [i.e., primordial prevention] through health promotion to avert the loss of health from early life when the burden, disparities, and costs of CVD and the other NCDs begin.”Labarthe DR, Dunbar SB. Global cardiovascular health promotion and disease prevention: 2011 and beyond. Circulation 2012;126:479-485


CVD PreventionCVH Promotion

Primordial Remedial


Recurrent CVD



Preserving Low

CVD Risk

4 Lines of action

Addressing cardiovascular health anddisease: time to re-set the balance?

4/2/2015 65

Implications

Theory – a new conceptual model

• The new focus on preserving ideal CVH is derived from and reinforces the concept of primordial prevention.

• It requires thinking more about the whole population and not those at increased risk – or ideal CVH - alone.

• It calls for increased attention to factors that determine the most favorable trajectories of CVH metrics and development of policies to promote them.

ImplicationsPractice – a new assessment of prevention policy

• For each CVH metric, policy guidance is needed for development or scaling up of programs to achieve the full potential impact of primordial prevention.

• Expanded monitoring of the metrics in childhood is needed, through NHANES and in clinical practice, in order to preserve those that are ideal, restore those that are intermediate, and reverse those that are poor.

ImplicationsResearch – a new emphasis on the life course, from childhood on

• Ongoing research continues to demonstrate the importance of low risk and the potential impact of the policy of primordial prevention.

• Studies are needed to elucidate the determinants of favorable trajectories of the CVH metrics and to discover effective interventions to promote and preserve ideal cardiovascular health.

AHA’s Strategically Focused Prevention Research Network - RFA

• …a call for innovation in research and training to address the AHA 2020 goal of improving CVH of all Americans, specifically including primordial prevention to avert and reverse the loss of ideal CVH from childhood onward.

RESEARCH THEME

• Low cardiovascular risk at age 50 predicts longer life free of CVD than presence of 1 or more risk factors.

• Ideal CVH (5+-6+ metrics) is rare at age 50 but common in children.

• Preserving and promoting ideal cardiovascular health from childhood throughout the life course would improve CVH and reduce CVD and stroke deaths, AHA’s combined 2020 Impact Goal.

POPULATION SCIENCE PROJECT PI, Norrina Bai Allen

Aims• Discover trajectories of the metrics and score• Identify predictors of the trajectories• Determine critical inflection points in the

trajectories• Assess associations of trajectories with

detected subclinical atherosclerosis

Approach• Pool data from 4 major studies: Bogalusa Heart

Study, Young Finns Study, Project HeartBeat!, and CARDIA

• For each metric and CVH score, apply latent-class modeling to define homogeneous subgroups of trajectories; identify predictors; and discover inflection points by age or stage of development

• Incorporate measures of subclinical athero-sclerosis as outcomes

POPULATION SCIENCE PROJECT PI, Norrina Bai Allen

Tota

l Cho

lest

erol

(mg/

dL)

Age (yrs)

Total CholesterolLow (44.0) Moderate (48.8) High (7.2)

240220

180160140

Conclusion:

We have the possibility, envisioned more than three decades ago, to arrest and reverse the epidemic of cardiovascular disease by promoting and preserving ideal cardiovascular health from the beginning, through primordial prevention, making the whole population in future generations heart disease and stroke free – thanks to this revolution.

From CVD to CVH: A Quiet Revolution---And Why It Matters

Darwin R. Labarthe MD, MPH, PhD Department of Preventive Medicine

WHFEL Think Tank SeminarLima, Peru – March 23-27, 2015

cdc salt e-update - world heart federation...2017/11/27 · mod + vig children 12-19 yo none >0...

Documents