CVD Definitions and Statistics Jan 2012.ppt

Cardiovascular Epidemiology
and Prevention
Nathan D. Wong, PhD, FACC, FAHA
Professor and Director, Heart Disease
Prevention Program, Division of
Cardiology, University of California, Irvine
President, American Society of Preventive
Cardiology

Cardiovascular Epidemiology:
Definitions, Concepts,
Historical Perspectives and
Statistics

Definitions
• CORONARY ARTERY DISEASE (CAD) or
CORONARY HEART DISEASE (CHD)
(often broadly referred to as ISCHEMIC
HEART DISEASE (IHD): primarily
myocardial infarction and sudden
coronary death, broader definition may
include angina pectoris, atherosclerosis,
positive angiogram, and revascularization
(perceutaneous coronary interventions, or
PCI such as angioplasty and stents)
• CARDIOVASCULAR DISEASE or CVD
includes CHD, cerebrovascular disease,
peripheral vascular disease, and other
cardiac conditions (congenital,
arrhythmias, and congestive heart failure)

Definitions (cont.)
• SURROGATE MEASURES include: carotid
intimal medial thickness (IMT), coronary
calcium, angiographic stenosis, brachial
ultrasound flow mediated dilatation (FMD)
• Hard endpoints include myocardial
infarction, CHD death, and stroke

CVD and other major causes of death for all males and females
(United States: 2007).
391,886
292,857
79,827
61,235
35,478
21,800
421,918
270,018
66,689
52,832
43,879
35,904
0
50,000
100,000
150,000
200,000
250,000
300,000
350,000
400,000
450,000
A B C D E F A B D F C E
Deaths
Males Females
Source: NCHS and NHLBI. A indicates CVD plus congenital CVD; B, cancer; C, accidents; D, CLRD; E, diabetes; and F, Alzheimer's disease.
©2010 American Heart Association, Inc. All rights reserved. Roger VL et al. Published online in Circulation Dec. 15, 2010

Trends in cardiovascular procedures, United States: 1979–2009
Note: Inpatient procedures only. Source: National Hospital Discharge Survey, NCHS, and NHLBI.
0
200
400
600
800
1000
1200
1400
1979 1980 1985 1990 1995 2000 2005 2009
Procedures
in
Thousands
Years
Catheterizations Bypass PCI Carotid Endarterectomy Pacemakers

Direct and indirect costs (in billions of dollars)
of major cardiovascular diseases and stroke (United States: 2008)
Source: National Heart, Lung, and Blood Institute.
190.3
50.6
34.3
22.5
0
20
40
60
80
100
120
140
160
180
200
Heart disease Hypertension Stroke Other CVD
Billions
of
Dollars

Projected Total Costs of CVD, 2015–2030 (in Billions 2008$) in the United States
564.9
121.1 132.4
44.6 69.1
197.8
704.7
153.2
156.9
57.0
87.1
250.5
886.2
194.1 186.7
74.1
111.2
320.0
1117.6
245.2 223.8
97.0
143.0
408.5
0
200
400
600
800
1000
1200
All CVD Hypertension CHD HF Stroke Other CVDs
Total
Dollars
(in
Billions)
2015 2020 2025 2030
Unpublished data tabulated by AHA using methods described in Circulation. 2011;123:933–944.

350
400
450
500
550
79 80 85 90 95 00 06
Years
Deaths
in
Thousands
Males Females

Hospital discharges for cardiovascular diseases.
(United States: 1970-2006). Note: Hospital discharges include
people discharged alive, dead and status unknown.
Source: NCHS and NHLBI.
0
1
2
3
4
5
6
7
70 75 80 85 90 95 00 06
Years
Discharges
in
Millions

14.2
39.3
72.6
80.1
9.7
37.2
71.9
86.7
0
10
20
30
40
50
60
70
80
90
100
20-39 40-59 60-79 80+
Percent
of
Population
Men Women
Prevalence of CVD in adults ≥20 years of age by age and sex (NHANES: 2005–2008)
Source: NCHS and NHLBI. These data include CHD, HF, stroke, and hypertension.

Deaths due to diseases of the heart (United States: 1900–2008)
0
200
400
600
800
1,000
1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2008
Deaths
in
Thousands
Years
Source: National Center for Health Statistics.

CVD deaths vs. cancer deaths by age.
(United States: 2006). Source: NCHS.
25
81
242
315
50
48
120
831
21
101
138 165
85
560
0
200
400
600
800
1,000
<45 45-54 55-64 65-74 75-84 85+ Total
Ages
Deaths
in
Thousands
CVD Cancer

CVD and other major causes of death for all males and females (United States: 2008)
Source: NCHS and NHLBI. A indicates CVD plus congenital CVD; B, cancer; C, accidents; D, CLRD; E, diabetes; and F, Alzheimer's disease.
392,210
295,259
78,378
67,122
35,346
24,516
419,730
270,210
73,968
57,919
43,524
35,207
0
50,000
100,000
150,000
200,000
250,000
300,000
350,000
400,000
450,000
A B C D E F A B D F C E
Deaths
Males Females

Prevalence of stroke by age and sex (NHANES: 2005–2008)
0.3
1.6
7.2
14.5
0.5
2.4
8.2
14.8
0
2
4
6
8
10
12
14
16
18
20-39 40-59 60-79 80+
Percent
of
Population
Age
Men Women

Prevalence of stroke by age and sex (NHANES: 2005–2008).
0.3
1.6
7.2
14.5
0.5
2.4
8.2
14.8
0
2
4
6
8
10
12
14
16
18
20-39 40-59 60-79 80+
Percent
of
Population
Age
Men Women

Percentage breakdown of deaths from cardiovascular diseases
(United States: 2006) * - Not a true underlying cause.
Source: NCHS.
51
17
7
7
4
14
Coronary Heart
Disease
Stroke
HF*
High Blood Pressure
Diseases of the
Arteries
Other

Prevalence of heart failure by age and sex
(NHANES: 2005-2006). Source: NCHS and NHLBI.
0.1
2.2
9.3
13.8
0.2
1.2
4.8
12.2
0
2
4
6
8
10
12
14
16
20-39 40-59 60-79 80+
Percent
of
Population
Men Women

Note: Hospital discharges include people discharged alive, dead
and status unknown.
Hospital discharges for heart failure by sex.
(United States: 1979-2006). Source: NHDS/NCHS and NHLBI.
0
100
200
300
400
500
600
700
79 80 85 90 95 00 06
Years
Discharges
in
Thousands
Male Female

Development of Atherosclerotic
Plaques
Normal
Fatty streak
Foam cells
Lipid-rich plaque
Lipid core
Fibrous cap
Thrombus
Ross R. Nature. 1993;362:801-809.

PDAY: Percentage of Right Coronary Artery
Intimal Surface Affected With Early Atherosclerosis
PDAY= Pathobiological Determinants of Atherosclerosis in Youth.
Strong JP, et al. JAMA. 1999;281:727-735.
Fatty streaks
Raised lesions
White
15-19 20-24 25-29 30-34
0
10
20
30 Women
0
10
20
30
15-1920-2425-2930-34
Black
Age (y)
0
10
20
30
White
15-19 20-24 25-29 30-34
Men
Black
15-19 20-24 25-29 30-34
0
10
20
30
Intimal
surface
(%)

Most Myocardial Infarctions Are Caused
by Low-Grade Stenoses
Pooled data from 4 studies: Ambrose et al, 1988; Little et al, 1988; Nobuyoshi et al, 1991; and Giroud et al,
1992.
(Adapted from Falk et al.)
Falk E et al, Circulation, 1995.

(Adapted from Glagov et al.)
Coronary Remodeling
Normal
vessel
Minimal
CAD
Progression
Compensatory expansion
maintains constant lumen
Expansion
overcome:
lumen narrows
Severe
CAD
Moderate
CAD
Glagov et al, N Engl J Med, 1987.

Intraluminal thrombus
Growth of thrombus
Intraplaque thrombus Lipid pool
Blood Flow
Atherosclerotic Plaque Rupture and
Thrombus Formation
Adapted from Weissberg PL. Eur Heart J Supplements
1999:1:T13–18

• Eccentric, lipid-rich
• Fragile fibrous cap
• Prior luminal
obstruction < 50%
• Visible rupture
and thrombus
Constantinides P. Am J Cardiol. 1990;66:37G-40G.
Features of a Ruptured
Atherosclerotic Plaque

Libby P. Circulation. 1995;91:2844-2850.
Vulnerable Plaque
• Thin fibrous cap
• Inflammatory cell infiltrates:
proteolytic activity
• Lipid-rich plaque
Lumen Lipid
Core
Fibrous Cap
• Thick fibrous cap
• Smooth muscle cells:
more extracellular matrix
• Lipid-poor plaque
Stable Plaque
Lumen Lipid
Core
Fibrous Cap
Vulnerable Versus Stable
Atherosclerotic Plaques

Correlation of CT angiography of the
coronary arteries with intravascular
ultrasound illustrates the ability of MDCT
to demonstrate calcified and non-calcified
coronary plaques (Becker et al., Eur J
Radiol 2000) Non-calcified, soft, lipid-rich plaque in
left anterior descending artery (arrow)
(Somatom Sensation 4, 120 ml Imeron
400). The plaque was confirmed by
intravascular ultrasound (Kopp et al.,
Radiology 2004)

Concept of cardiovascular
“risk factors”
Kannel et al, Ann Intern Med 1961
Age, sex, hypertension, hyperlipidemia, smoking, diabetes,
(family history), (obesity)

Major Risk Factors
• Cigarette smoking (passive smoking?)
• Elevated total or LDL-cholesterol
• Hypertension (BP 140/90 mmHg or on
antihypertensive medication)
• Low HDL cholesterol (<40 mg/dL)†
• Family history of premature CHD
– CHD in male first degree relative <55
years
– CHD in female first degree relative <65
years
• Age (men 45 years; women 55 years)
† HDL cholesterol 60 mg/dL counts as a “negative” risk factor; its
presence removes one risk factor from the total count.

Other Recognized Risk
Factors
• Obesity: Body Mass Index (BMI)
– Weight (kg)/height (m2)
– Weight (lb)/height (in2) x 703
• Obesity BMI >30 kg/m2 with overweight
defined as 25-<30 kg/m 2
• Abdominal obesity involves waist
circumference >40 in. in men, >35 in. in
women
• Physical inactivity: most experts
recommend at least 30 minutes moderate
activity at least 4-5 days/week

Prevalence (unadjusted) estimates for poor, intermediate and ideal cardiovascular health
for each of the 7 metrics of cardiovascular health in the AHA 2020 goals,
US children aged 12-19 years, NHANES 2007-2008

Age-standardized prevalence for poor, intermediate and ideal cardiovascular health for each
of the 7 metrics of cardiovascular health in the AHA 2020 goals,
among US adults >20 years of age, NHANES 2007-2008

Lifetime Risk of Coronary Heart Disease
in the Framingham Study
Men Women
At age 40 years: 48.6% 31.7%
At age 70 years: 34.9% 24.2%
Lloyd-Jones et al. Lancet 1999; 353:89-92
____________________________________________________________
______________________________________________________________
_________________________________________________________________

First Coronary Events: Framingham
Study
Percent as Specified Event
Myocardial Angina Sudden
Infarction Pectoris Death
Age Men Women Men Women Men Women
35-64 43% 28% 41% 59% 9% 4%
65-84 55% 44% 28% 41% 11% 7.4%
Framingham Study 44 year follow-up.
____________________________________________________________
________________________________________________________
____________________________________________________________

Estimated 10-Year CHD Risk in
55-Year-Old Adults According to Levels
of Various Risk Factors
Framingham Heart Study
A B C D
Blood Pressure (mm Hg) 120/80 140/90 140/90 140/90
Total Cholesterol (mg/dL) 200 240 240 240
HDL Cholesterol (mg/dL) 50 50 40 40
Diabetes No No Yes Yes
Cigarettes No No No Yes
mm Hg = millimeters of mercury
mg/dL = milligrams per deciliter of blood
Source: Circulation 1998;97:1837-1847.
5
13
25
5
8
20
27
37
0
5
10
15
20
25
30
35
40
A B C D
Estimated
10-Year
Rate
(%)
Men
Women

2.6
4
5.4
8.4
1.1 2
19.1
22.4
14.8
27
6.3
3.5
0
5
10
15
20
25
30
A B C D E F
Estimated
10-Year
Rate
(%)
Men Women
Estimated 10-Year Stroke Risk in 55-
Year-Old Adults According to Levels of
Various Risk Factors
Framingham Heart Study
A B C D E F
Systolic BP* 95-105 130-148 130-148 130-148 130-148 130-148
Diabetes No No Yes Yes Yes Yes
Cigarettes No No No Yes Yes Yes
Prior Atrial Fib. No No No No Yes Yes
Prior CVD No No No No No Yes
Source: Stroke 1991;22:312-318. *BP in millimeters of mercury (mmHg)

Offspring CVD Risk by Parental CVD Status:
Framingham Study
0
0.5
1
1.5
2
2.5
MEN WOMEN
NONE
MATERNAL
PATERNAL
Risk Ratio
2.5
2
1.5
1
0.5
0
Men Women
1.0
1.7
2.2
1.0
1.7 1.7
Adjusted for: age, total/HDL Chol. ratio, SBP, smoking, diabetes, BMI
Parental CVD <55
men, <65 Women

Multivariable Risk
Risk imposed by a strong family
history of heart attacks varies widely
depending on the burden of
modifiable risk factors

9
Doubts about
cholesterol as
late as 1989

Lifetime Risk of CHD Increases with Serum
Cholesterol
0
10
20
30
40
50
60
Percent
Men Women
<200 mg
200-239 mg
>240 mg
Framingham Study: Subjects age 40 years
DM Lloyd-Jones et al Arch Intern Med 2003; 1966-1972
34
44
57
19
29
33
Cholesterol
___________________________________________________________________________
_______________________________________________________________________________

Q = serum cholesterol quintile.
Kannel WB et al. Am Heart J. 1986;112:825-836.
Multiple Risk Factor Intervention Trial (MRFIT)
N=325,346
Correlation Between Serum
Cholesterol and CVD Mortality
6-Year
CVD
Death
Rate
Per
1000
0
5
10
15
20
25
30
Q1
(<182)
Q2
(182-202)
Q3
(203-220)
Q4
(221-244)
Q5
(>244)
35-39 years
40-44 years
45-49 years
50-54 years
55-57 years
Serum Cholesterol Quintile (mg/dL)
Untreated Patients

Trends in mean total serum cholesterol among adolescents 12–17 years of
age by race, sex, and survey year (NHANES: 1988–1994*, 1999–2004 and
2005-2008).
163
165
166
174
159
161
163 163
158
160
154
157
161
162
155
158
140
145
150
155
160
165
170
175
180
NH White Males NH Black Males NH White
Females
NH Black Females Mex. Am. Males Mex. Am. Females
Mean
Total
Blood
Cholesterol
1988-94 1999-2004 2005-2008
Source: NCHS and NHLBI. NH indicates non-Hispanic. Mex. Am. indicates Mexican American.
* Data for Mexican Americans not available.

Trends in mean total serum cholesterol among adults ages ≥20
by race and survey year,
(NHANES: 1988–1994, 1999–2004 and 2005–2008).
206
204
205
203
198
201
198
192
201
180
185
190
195
200
205
210
NH White NH Black Mexican American
Mean
Serum
Total
Cholesterol
1988-94 1999-2004 2005-2008
Source: NCHS and NHLBI. NH indicates non-Hispanic.

CK Friedberg on Hypertension:
Diseases of the Heart 1996
“There is a lack of correlation in
most cases between the severity
and duration of hypertension and
development of cardiac
complications.”
___________________________________________________________
________________________________________________________
_______________________________________________________________

Relation of Non-Hypertensive Blood
Pressure to Cardiovascular Disease
Vasan R, et al. N Engl J Med 2001; 345:1291-1297
0%
2%
4%
6%
8%
10%
12%
Women Men
<120/80 mm Hg
120-129/80-84 mm Hg
130-139/85-89 mm Hg
10-year Age- Adjusted Cumulative Incidence
Hazard Ratio*
SBP Women Men
<120/80 1.0 1.0
120-129 1.5 1.3
130-139 2.5 1.6
H.R. adjusted for age,
BMI, Cholesterol, Diabetes
and smoking *P<.001
Framingham Study: Subjects Ages 35-90 yrs.
1.9
2.8
4.4
5.8
7.6
10.1

Prevalence of High Blood Pressure in adults ≥20 years of age
by age and sex (NHANES: 2005–2008)
11.1
25.1
37.1
54.0
64.0
66.7
6.8
19.0
35.2
53.3
69.3
78.5
0
10
20
30
40
50
60
70
80
90
20-34 35-44 45-54 55-64 65-74 75+
Percent
of
Population
Age
Male Female
Source: NCHS and NHLBI. Hypertension is defined as SBP 140 mm Hg or DBP 90 mmHg, taking antihypertensive medication, or being told twice by a
physician or other professional that one has hypertension.

Extent of awareness, treatment and control of high blood pressure
by race/ethnicity (NHANES : 2005-2006).
70.1
78.8
69.1
45.4
79.0
46.1
74.7
82.3
46.5
67.6
52.1
35.2
0
10
20
30
40
50
60
70
80
90
Awareness Treatment Controlled
Percent
of
Population
With
Hypertension
Total Population NH Whites NH Blacks Mexican Americans

CK Friedberg on Hypertension
Diseases of the Heart 1966
“Hypertension imposes a load on
the heart which for many years
may be compensated by left
ventricular hypertrophy”
_______________________________________________________________
_______________________________________________________________

CVD Risk Imposed by ECG-LVH
Framingham Study 36-yr. Follow-up
Age-adjusted Risk Excess Risk
Rate per 1000 Ratio per 1000
Age Men Women Men Women Men Women
35-64 164 135 4.7*** 7.4*** 129 117
65-94 234 235 2.8*** 4.1*** 51 178
Biennial Rate per 1000. CVD=CHD, stroke,
peripheral vascular disease, heart failure
***P<0.001
_______________________________________________________________
_______________________________________________________________
_____________________________________________________________

Smoking Statement Issued in 1956 by
American Heart Association
“It is the belief of the committee that much
greater knowledge is needed before any
conclusions can be drawn concerning
relationships between smoking and
death rates from coronary heart
disease. The acquisition of such
knowledge may well require the use of
techniques and research methods that
have not hitherto been applied to this
problem.”
___________________________________________________________
____________________________________________________________
___________________________________________________________

CHD Risk by Cigarette Smoking. Filter
Vs. Non-filter. Framingham Study. Men
<55 Yrs.
0
50
100
150
200
250
Total CHD Myocardial
Infarction
Non-Smoker
Reg. Cig. Smoker
Filter Cig. Smoker
14-yr. Rate/1000
119
206
210
59
112
210

Prevalence of students in grades 9 to 12 reporting current cigarette use
by sex and race/ethnicity (YRBSS, 2009)
22.3
10.7
19.4
22.8
8.4
16.7
0
5
10
15
20
25
NH White NH Black Hispanic
Percent
of
the
Population
Males Females
Source: MMWR Surveill Summ. 2010;59:1–142.NH indicates non-Hispanic.

Prevalence of current smoking for adults > 18 years of age
by race/ethnicity and sex (NHIS: 2007-2009)
All percentages are age-adjusted. NH indicates non-Hispanic. *Includes both Hispanics and non-Hispanics. Data derived from Centers for Disease Control
and Prevention/National Center for Health Statistics, Health Data Interactive.
22.9
18.9
23.6
17.0
17.9
9.3
15.4
5.4
26.8
19.9
0
5
10
15
20
25
30
Men Women
Percent
of
Population
NH White NH Black Hispanic Asian* American Indian/Alaska Native*

Prevalence of current smoking for adults > 18 years of age
by race/ethnicity and sex (NHIS: 2006-2008)
24.0
21.0
25.0
17.1
18.4
9.4
15.7
4.5
30.2
22.1
0
5
10
15
20
25
30
35
Men Women
Percent
of
Population
NH White NH Black Hispanic Asian* American Indian/Alaska Native*
Source: CDC/NCHS, Health Data Interactive. All percentages are age-adjusted. NH indicates non-Hispanic.
* Includes both Hispanics and non-Hispanics.

Diseases of The Heart
Charles K Friedberg MD, WB
Saunders Co. Philadelphia, 1949
“The proper control of diabetes is
obviously desirable even though
there is uncertainty as to whether
coronary atherosclerosis is more
frequent or severe in the
uncontrolled diabetic”
________________________________________________________________
______________________________________________________________

Risk of Cardiovascular Events in Diabetics
Framingham Study
Age-adjusted
Biennial Rate Age-adjusted
Per 1000 Risk Ratio
Cardiovascular Event Men Women Men Women
Coronary Disease 39 21 1.5** 2.2***
Stroke 15 6 2.9*** 2.6***
Peripheral Artery Dis. 18 18 3.4*** 6.4***
Cardiac Failure 23 21 4.4*** 7.8***
All CVD Events 76 65 2.2*** 3.7***
Subjects 35-64 36-year Follow-up **P<.001,***P<.0001
_________________________________________________________________
_________________________________________________________________

Age-adjusted prevalence of physician-diagnosed diabetes in
adults ≥20 years of age
by race/ethnicity and sex (NHANES: 2005–2008).
6.8
6.5
14.3
14.7
11.0
12.7
0
2
4
6
8
10
12
14
16
Male Female
Percent
of
Population
NH White NH Black Mexican American
Source: NCHS and NHLBI. NH indicates non-Hispanic.

Trends in diabetes prevalence in adults ≥20 years of age, by
sex
(NHANES: 1988–1994 and 2005–2008).
5.4
3.4
7.9
4.1
5.4
2.5
8.2
2.3
0
1
2
3
4
5
6
7
8
9
Physician Diagnosed 1988-94 Undiagnosed 1988-94 Physician Diagnosed 2005-08 Undiagnosed 2005-08
Percent
of
Population
Male Female
Source: NCHS, NHLBI.

Skepticism About Importance of Obesity
Keys A, Aravanis C, Blackburn H, et al. Ann Intern Med 1972;
77:15-27.
Concluded that all the excess risk of coronary heart
disease in the obese derives from its atherogenic
accompaniments, illogically leaving the impression that obesity
is therefore unimportant.
Mann GV. N Engl J Med 1974; 291:226-232.
“The contribution of obesity to CHD is either small or
non-existent. It cannot be expected that treating obesity is
either logical or a promising approach to the management of
CHD”.
Barrett-Connor EL. Ann Intern Med 1985; 103:1010-1019
NIH consensus panel is equivocal about the role of
obesity as a cause of CHD.

Relation of Weight Change to Changes in
Atherogenic Traits: The Framingham Study
Frantz Ashley, Jr. and William B Kannel
J Chronic Dis 1974
“Weight gain is accompanied by atherogenic alterations in
blood lipids, blood pressure, uric acid and carbohydrate
tolerance.”
“It seems reasonable to expect that correction of overweight
will improve the coronary risk problem.”
“Avoidance of overweight would seem a desirable goal in the
general population if the appalling annual toll from disease
is to be substantially reduced.”

4.0
6.1
6.5
5.0
11.3
10.5
15.9 16.0
17.4
17.9
0
2
4
6
8
10
12
14
16
18
20
6-11 12-19
Percent
of
Population
Age (Years)
1971-1974 1976-1980 1988-1994 1999-2002 2005-2008
Trends in the prevalence of obesity among US children and adolescents by age and survey year
(National Health and Nutrition Examination Survey: 1971-1974, 1976-1980, 1988-1994, 1999-
2002 and 2005–2008)
Data derived from Health, United States, 2010: With Special Feature on Death and Dying. NCHS, 2011.

Age-adjusted prevalence of obesity in adults 20–74 years of age, by sex and survey year
(NHES: 1960–62; NHANES: 1971–74, 1976–80, 1988–94, 1999-2002 and 2005-08)
10.7
15.7
12.2
16.8
12.8
17.1
20.6
26.0
28.1
34.0
33.3
36.2
0
5
10
15
20
25
30
35
40
Men Women
Percent
of
Population
1960-62 1971-74 1976-80 1988-94 1999-2002 2005-08
Data derived from Health, United States, 2010: With Special Feature on Death and Dying. NCHS, 2011.

3
2.4
1.8
1.2
0.6
0
(1971) (1989)
Q1 Q2 Q3 Q4 Q5 Overall
Thin Obese
Risk Factor Sum and Obesity
(1971-74) and (1989-93)
Risk
Factor
Sum
Risk variables include bottom quintile for HDL-C and top
quintiles for cholesterol, SBP, triglycerides and glucose Wilson PWF, & Kannel WB
Nutr Clin Care 1999; 1:44-50
Framingham Study
Risk factors accumulate with weight gain

Prevalence of students in grades 9–12 who met currently
recommended levels of PA
during the past 7 days by race/ethnicity and sex (YRBS: 2009).
47.3
31.3
43.3
21.9
41.3
24.9
0
5
10
15
20
25
30
35
40
45
50
Male Female
Percent
of
Population
Currently recommended levels is defined as activity that increased their heart rate and made them breathe hard some of the time for a total of at least
60 minutes per day on 5 of the 7 days preceding the survey. Source: MMWR Surveillance Summaries.1 NH indicates non-Hispanic.

Prevalence of regular leisure-time physical activity among
adults > 18 years of age
by race/ethnicity and sex (NHIS: 2009).
40.1
36.2
36.0
24.1
29.7
25.9
0
5
10
15
20
25
30
35
40
45
Men Women
Percent
of
Population
Source: Pleis et al, 2010. NH indicates non-Hispanic. Percents are age-adjusted. Regular leisure-time physical activity is defined as 3 or more sessions
per week of vigorous activity lasting at least 20 minutes or five or more sessions per week of light/moderate activity lasting at least 30 minutes.

Prevalence of students in grades 9 to 12 reporting current
cigarette use
by sex and race/ethnicity (YRBSS, 2009).
22.3
10.7
19.4
22.8
8.4
16.7
0
5
10
15
20
25
Percent
of
the
Population
Males Females
Source: MMWR Surveill Summ. 2010;59:1–142.NH indicates non-Hispanic.

Risk Assessment
Count major risk factors
• For patients with multiple (2+) risk
factors
– Perform 10-year risk assessment
• For patients with 0–1 risk factor
– 10 year risk assessment not required
– Most patients have 10-year risk <10%

ATP III Assessment of CHD Risk
For persons without known CHD, other forms of
atherosclerotic disease, or diabetes:
• Count the number of risk factors:
– Cigarette smoking
– Hypertension (BP 140/90 mmHg or on
antihypertensive medication)
– Low HDL cholesterol (<40 mg/dL)†
– Family history of premature CHD
 CHD in male first degree relative <55 years
 CHD in female first degree relative <65 years
– Age (men 45 years; women 55 years)
• Use Framingham scoring for persons with 2
risk factors* (or with metabolic syndrome) to
determine the absolute 10-year CHD risk.
(downloadable risk algorithms at
www.nhlbi.nih.gov)
Expert Panel on Detection, Evaluation, and Treatment of
High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.
© 2001, Professional Postgraduate Services®
www.lipidhealth.org

Note: Risk estimates were derived from the experience of the Framingham Heart Study,
a predominantly Caucasian population in Massachusetts, USA.
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults.
JAMA. 2001;285:2486-2497.
Assessing CHD Risk in Men
Step 1: Age
Years Points
20-34 -9
35-39 -4
40-44 0
45-49 3
50-54 6
55-59 8
60-64 10
65-69 11
70-74 12
75-79 13
Step 2: Total Cholesterol
TC Points at Points at Points at Points
at Points at
(mg/dL) Age 20-39 Age 40-49 Age 50-59 Age 60-69 Age
70-79
<160 0 0 0 0 0
160-199 4 3 2 1 0
200-239 7 5 3 1 0
240-279 9 6 4 2 1
280 11 8 5 3 1
HDL-C
(mg/dL) Points
60 -1
50-59 0
40-49 1
<40 2
Step 3: HDL-Cholesterol
Systolic BP Points Points
(mm Hg) if Untreated if Treated
<120 0 0
120-129 0 1
130-139 1 2
140-159 1 2
160 2 3
Step 4: Systolic Blood Pressure
Step 5: Smoking Status
Points at Points at Points at Points
at Points at
Age 20-39 Age 40-49 Age 50-59 Age 60-69 Age
70-79
Nonsmoker 0 0 0 0 0
Smoker 8 5 3 1 1
Age
Total cholesterol
HDL-cholesterol
Systolic blood pressure
Smoking status
Point total
Step 6: Adding Up the Points
Point Total 10-Year Risk Point Total 10-Year
Risk
<0 <1% 11 8%
0 1% 12 10%
1 1% 13 12%
2 1% 14 16%
3 1% 15 20%
4 1% 16 25%
5 2% 17 30%
6 2%
7 3%
8 4%
9 5%
10 6%
Step 7: CHD Risk
ATP III Framingham Risk Scoring
www.lipidhealth.org

Risk
<9 <1% 20 11%
9 1% 21 14%
10 1% 22 17%
11 1% 23 22%
12 1% 24 27%
13 2% 25 30%
14 2%
15 3%
16 4%
17 5%
18 6%
19 8%
Assessing CHD Risk in Women
Note: Risk estimates were derived from the experience of the Framingham Heart Study,
a predominantly Caucasian population in Massachusetts, USA.
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults.
JAMA. 2001;285:2486-2497.
Step 1: Age
Years Points
20-34 -7
35-39 -3
40-44 0
45-49 3
50-54 6
55-59 8
60-64 10
65-69 12
70-74 14
75-79 16
TC Points at Points at Points at Points
at Points at
70-79
<160 0 0 0 0 0
160-199 4 3 2 1 1
200-239 8 6 4 2 1
240-279 11 8 5 3 2
280 13 10 7 4 2
HDL-C
(mg/dL) Points
60 -1
50-59 0
40-49 1
<40 2
<120 0 0
120-129 1 3
130-139 2 4
140-159 3 5
160 4 6
Points at Points at Points at Points
at Points at
70-79
Nonsmoker 0 0 0 0 0
Smoker 9 7 4 2 1
Age
Total cholesterol
HDL-cholesterol
Smoking status
Point total
Step 7: CHD Risk
www.lipidhealth.org

Men
Years Points
20-34 -9
35-39 -4
40-44 0
45-49 3
50-54 6
55-59 8
60-64 10
65-69 11
70-74 12
75-79 13
Step 1: Age
Expert Panel on Detection, Evaluation, and Treatment of High Blood
Cholesterol in Adults. JAMA. 2001;285:2486-2497.
Women
Years Points
20-34 -7
35-39 -3
40-44 0
45-49 3
50-54 6
55-59 8
60-64 10
65-69 12
70-74 14
75-79 16
www.lipidhealth.org

Note: TC and HDL-C values should be the average of at least two fasting
lipoprotein measurements.
Men TC Points at Points at Points at Points at Points
at
70-79
<160 0 0 0 0 0
160-199 4 3 2 1 0
200-239 7 5 3 1 0
240-279 9 6 4 2 1
280 11 8 5 3 1
Women
TC Points at Points at Points at Points atPoints at
(mg/dL) Age 20-39 Age 40-49 Age 50-59 Age 60-69 Age 70-
79
<160 0 0 0 0 0
160-199 4 3 2 1 1
200-239 8 6 4 2 1
240-279 11 8 5 3 2
280 13 10 7 4 2
www.lipidhealth.org

Note: HDL-C and TC values should be the average of at least two
fasting lipoprotein measurements.
Men
HDL-C
(mg/dL) Points
60 -1
50-59 0
40-49 1
<40 2
Women
HDL-C
(mg/dL) Points
60 -1
50-59 0
40-49 1
<40 2
www.lipidhealth.org

Men
<120 0 0
120-129 0 1
130-139 1 2
140-159 1 2
160 2 3
Note: The average of several BP measurements is needed for an accurate
measurement of baseline BP. If an individual is on antihypertensive treatment,
extra points are added.
Women
<120 0 0
120-129 1 3
130-139 2 4
140-159 3 5
160 4 6
www.lipidhealth.org

Note: Any cigarette smoking in the past month.
Men
Points at Points at Points at Points at Points
at
70-79
Nonsmoker 0 0 0 0 0
Smoker 8 5 3 1 1
Women
Points at Points at Points at Points at Points
at
70-79
Nonsmoker 0 0 0 0 0
Smoker 9 7 4 2 1
www.lipidhealth.org

(Sum From Steps 1–5)
Age
Total cholesterol
HDL-cholesterol
Smoking status
Point total
www.lipidhealth.org

Step 7: CHD Risk for Men
Note: Determine the 10-year absolute risk for hard CHD (MI and
coronary death) from point total.
Risk
<0 <1% 11 8%
0 1% 12 10%
1 1% 13 12%
2 1% 14 16%
3 1% 15 20%
4 1% 16 25%
5 2% 17 30%
6 2%
7 3%
8 4%
9 5%
10 6%
www.lipidhealth.org

Presentation
• Examination:
– Height: 6 ft 2 in
– Weight: 220 lb (BMI 28
kg/m2)
– Waist circumference: 41
in
– BP: 150/88 mm Hg
– P: 64 bpm
– RR: 12 breaths/min
• Cardiopulmonary exam:
normal
• Laboratory results:
– TC: 220 mg/dL
– HDL-C: 36 mg/dL
– LDL-C: 140 mg/dL
– TG: 220 mg/dL
– FBS: 120 mg/dL

What is WJC’s 10-year absolute
risk
of fatal/nonfatal MI?
• A 12% absolute risk is derived from points
assigned in Framingham Risk Scoring to:
– Age: 6
– TC: 3
– HDL-C: 2
– SBP: 2
– Total: 13 points
In 1992 he exercised 14 minutes in a Bruce protocol exercise
stress test to 91% of his maximum predicted heart rate without
any abnormal ECG changes. He started on a statin in 2001.
But in Sept 2004, he needed urgent coronary bypass surgery.

Step 7: CHD Risk for Women
Note: Determine the 10-year absolute risk for hard CHD (MI and
coronary death) from point total.
Risk
<9 <1% 20 11%
9 1% 21 14%
10 1% 22 17%
11 1% 23 22%
12 1% 24 27%
13 2% 25 30%
14 2%
15 3%
16 4%
17 5%
18 6%
19 8%
www.lipidhealth.org

CHD Risk Equivalents
• Risk for major coronary events
equal to that in established CHD
• 10-year risk for hard CHD >20%
Hard CHD = myocardial infarction + coronary
death

Diabetes as a CHD Risk
Equivalent
• 10-year risk for CHD  20%
• High mortality with established CHD
– High mortality with acute MI
– High mortality post acute MI

CHD Risk Equivalents
• Other clinical forms of
atherosclerotic disease (peripheral
arterial disease, abdominal aortic
aneurysm, and symptomatic carotid
artery disease)
• Diabetes
• Multiple risk factors that confer a 10-
year risk for CHD >20%

Framingham 10-year Total CVD
Risk Algorithm (D’Agostino et al
2008)

International Comparisons in
CVD Morbidity and Mortality
• CVD accounts for 25-45% of deaths
among different countries
• CVD death rates (per 100,000)
range from 1310 in Russia to 201 in
Japan (6.5 fold difference) in men
and from 581 in Russia to 84 in
France (7-fold difference)
• USA ranks 16th for both men (413)
and women (201)

Secular Trends in CHD and
Stroke Mortality
• From 1985-1992, greatest annual
decline (6-7%) in CHD seen in Israel
among men and France among
women, USA intermediate (4%),
increases in Poland and Romania.
• Stroke death rates declined most in
Australia, Italy, and France (8-9%),
USA about 3%.

Age-Adjusted Death Rates for Coronary Heart Disease by Country and Sex,
Ages 35-74, 1999
•Age-Adjusted to European Standard
•Data for 1999 unless noted
Source: NHLBI 2002 Chart Book on Cardiovascular, Lung, and Blood Diseases

Age-Adjusted Death Rates for Stroke by Country and Sex, Ages 35-74, 1999
•Data for 1999 unless noted

Change in Age-Adjusted Death Rates for Coronary Heart Disease by Country and
Sex, Ages 35-74, 1990-1999
•Latest data year note in parentheses
Men
Women

Change in Age-Adjusted Death Rates for Stroke by Country and Sex, Ages 35-74,
1990-1999
•Latest data year note in parentheses
Men
Women

Migrant Studies
• Ni-Hon-San Study showed
Japanese living in Japan to have
the lowest cholesterol levels and
lowest rates of CHD, those living in
Hawaii to have intermediate rates
for both, and those living in San
Francisco to have the highest
cholesterol levels and CHD
incidence

Pyramid of Risk
(Werner et al. Canadian Journal of
Cardiology 1998; 14(Suppl) B:3B-10B)

Approaches to Primary and
Secondary Prevention of
CVD
• Primary prevention involves prevention
of onset of disease in persons without
symptoms.
• Primordial prevention involves the
prevention of risk factors causative o
the disease, thereby reducing the
likelihood of development of the
disease.
• Secondary prevention refers to the
prevention of death or recurrence of
disease in those who are already
symptomatic

Risk Factor Concepts in
Primary Prevention
• Nonmodifiable risk factors include age,
sexc, race, and family history of CVD,
which can identify high-risk populations
• Behavioral risk factors include sedentary
lifestyle, unhealthful diet, heavy alcohol
or cigarette consumption.
• Physiological risk factors include
hypertension, obesity, lipid problems,
and diabetes, which may be a
consequence of behavioral risk factors.

Population vs. High-Risk
Approach
• Risk factors, such as cholesterol or blood
pressure, have a wide bell-shaped distribution,
often with a “tail” of high values.
• The “high-risk approach” involves
identification and intensive treatment of those
at the high end of the “tail”, often at greatest
risk of CVD, reducing levels to “normal”.
• But most cases of CVD do not occur among the
highest levels of a given risk factor, and in fact,
occur among those in the “average” risk group.
• Significant reduction in the population burden
of CVD can occur only from a “population
approach” shifting the entire population
distribution to lower levels.

Expected Shifts in Cholesterol Distribution
from High-Risk, Population, and
Combined Approaches

Population and Community-
Wide CVD Risk Reduction
Approaches
• Populations with high rates of CVD are those with
Western lifestyles of high-fat diets, physical
inactivity, and tobacco use.
• Targets of a population-wide approach must be
these behaviors causative of the physiologic risk
factors or directly causative of CVD.
• Requires public health services such as
surveillance (e.g.,BFRSS), education (AHA,
NCEP), organizational partnerships (Singapore
Declaration), and legislation/policy (Anti-Tobacco
policies)
• Activities in a variety of community settings:
schools, worksites, churches, healthcare
facilities, entire communities

A conceptual framework for public
health practice in CVD prevention.
(From Pearson et al., J Public Health. 2001; 29:69 –78)

Communitywide CVD
Prevention Programs
• Stanford 3-Community Study (1972-75)
showed mass media vs. no intervention in
high-risk residents to result in 23% reduction
in CHD risk score
• North Karelia (1972-) showed public education
campaign to reduce smoking, fat
consumption, blood pressure, and cholesterol
• Stanford 5-City Project (1980-86) showed
reductions in smoking, cholesterol, BP, and
CHD risk
• Minnesota Heart Health Program (1980-88)
showed some increases in physical activity
and in women reductions in smoking

Materials Developed for US
Community Intervention
Trials
• Mass media, brochures and direct mail
• Events and contests
• Screenings
• Group and direct education
• School programs and worksite
interventions
• Physician and medical setting programs
• Grocery store and restaurant projects
• Church interventions
• Policies

Individual and High-Risk
Approaches
• Primary Prevention Guidelines (1995) and
Secondary Prevention Guidelines (Revised 2001)
released by the American Heart Association
provide advice regarding risk factor assessment,
lifestyle modification, and pharmacologic
interventions for specific risk factors
• Barriers exist in the community and healthcare
setting that prevent efficient risk reduction
• Surveys of CVD prevention-related services show
disappointing results regarding cholesterol-
lowering therapy, smoking cessation, and other
measures of risk reduction

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