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Towards the End of Vascular Disease in the s t 21 Century

Dr Muhammad Ayaz Bhatti Department of Community Medicine

Leaning objectives

LECTURE TWO

Preventive cardiology is the branch of medical science which deals with the prevention of cardiovascular problems and their treatment and rehabilitation.

PREVENTION OF CVD
WHO expert committee recommended on the prevention of CVD as follows. A.
Population Strategy. Prevention in the whole populations. Primordial prevention in the whole populations.

B. C.

High Risk strategy Secondary prevention

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Population Strategy.

CHD

a mass disease. focuses control of underlying causes (Risk

Approach

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. Dietary Changes.

The Goal should be smoke free society

2. Smoking

3. Blood Pressure

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4. Physical Activity

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A. PRIMORDIAL PREVENTION

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B. i. ii.

HIGH RISK STRATEGY Identifying risk groups Give them advice

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C. SECONDARY PREVENTION
Prevent recurrence and progression of CHD (Drug trials, coronary surgery, pace makers

Principles governing secondary prevention are

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D. TERTIARY PREVENTION

Revascularization procedures for patients with Angina pectoris.

Coronary artery By Pass Grafting CABG Percutaneous Transluminal Angioplasty PTCA

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Causal Process in Atherosclerosis

Hypertension Diabetes Diet High in Animal Fat Elevated Cholesterol Physical Inactivity Atherosclerosis

Smoking

Percent of Energy from Different Food Components

HunterGatherers 15-20 Peasant Agriculturalists 10-15 5 14+ Modern Affluent Societies

Fat

50-70

60-75

20

Sugar

25-30 15-20 10-15 Salt (g/d) Fiber (g/d) 1 40 5-15 60-120 12 10 20

Starch

Protein

CHD and Fat Intake in 40 Countries

CHD and Milk Intake in 40 Countries

Serum Cholesterol and Relative Risk of CHD, MRFIT

500
CHD = ICD-9 410-414, 429.2. Data source: CDC Wonder

The Development Process of CVD

Pathway Social and Environmental Conditions Target Population Whole Population Whole Population Persons with Risk Factors Cases with First Fatal or Non-Fatal Events Survivors Late Deaths Adverse Behavioral Patterns Major Risk Factors First Event/ Sudden Death Disability/ Risk of Recurrence Late Death

Interventions Policy and Environmental Change Behavior Change Risk Factor Detection and Control Emergency Care/Acute Case Management Rehabilitation /Long-Term Care End-OfLife Care

CHD among Low and High Risk Men in MRFIT

70 60 50

CHD

40 30 20 10 0 SBP: Chol: Smoking: <118 <182 No 125-131 203-220 No 125-131 203-220 Yes >142 >245 Yes

Phases of CHD Decline in the US

Phase 1 85 1960- Rapid fall in mortality; in smoking and intake of animal fat; Treatment of high BP. Significant

Phase 2 2000

1985 National decline slows for all but white men; Large regional/ethnic disparities emerge; Tertiary care plays a bigger role.

?? Phase Decline continues for all groups; High 3 2000 15 cholesterol now effectively treated; Cigarette smoking drops to low levels; Dietary goals achieved; Obesity/diabetes epidemic reversed.

How Can We Eliminate CHD as a Mass Disease?

1. 2. 3. 4. 5. 6. Eliminate smoking Reduce total fat to <20% of calories, and saturated fat to <7% Reduce dietary salt to <3% gm/day Control diabetes/obesity through fitness Treat high BP and high cholesterol Assure that all segments of society receive equal benefit

Steps to Eliminate Vascular Disease

1. Cigarettes
* * * tax Enforce sales laws Mount vigorous anti-smoking advertising campaign

Steps to Eliminate Vascular Disease

continued

2. Food
* * * salt content 5% / year Regulate fast food industry Promote alternate take out foods

Steps to Eliminate Vascular Disease

continued

3. Obesity/Exercise
* * * * Take up 10% of streets Create walking and bike boulevards Require employers to provide exercise facilities Restore PE in schools

Steps to Eliminate Vascular Disease

continued

4. Racial/Ethnic/SES Disparities
* * * Develop national health system Invest in economically depressed regions/neighborhoods Provide Scandinavian level social services

SURVEYS

The widely reported intervention trials are

1. 2.

FRAMINGHAM HEART STUDY The Stanford Heart Disease prevention programme in California. The North Kerelia Project in Finland The OSLO study The Multiple Risk Factor Intervention Trial (MRFIT in USA Lipid Research Clinics Study.

3. 4. 5.

6.

FRAMINGHAM HEART STUDY

1. 2.

1951 one of the best known Prospective study Established the nature of risk factors and their relative importance . Major risk factors were identified. According to this study four main possibilities to intervention in prevention of Reduction of serum cholesterol Cessation of smoking Control of hypertension Promotion of physical activity.

3. 4.

5. 6. 7. 8.

The Stanford Heart Disease prevention programme in California.

To determine whether community health education can reduce the risk of cardiovascular disease a field experiment was undertaken in 1972 in three towns with population varying 12000 to 15000. in two towns intensive mass education campaigns were conducted . 2. The third community served as control 3. 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.
1.

The 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 reduce the high level of risk factors for CVD(smoking, blood promote the early diagnosis, treatment and rehabilitation of pressure and serum cholesterol).

1. To

2. To

patients with CVD.

The North Kerelia Project in Finland continued

A

control population was established in a neighbouring country which has similar CV mortality The main strategy was employed community action against risk factors and advice on their avoidance. Follow up 5 years demonstrated a significant reduction in all three major risk factors. By 1979 mortality began to decline by 24 % in men and 51% in women compared with 12% in men and 26% in rest of Finland.

MRFIT the multiple Risk Factor Intervention Trial

Carried

years. Half group randomly allocated to an intervention programme being seen every 4 months to ensure adequate control of risk factors. The other half Control group received medical examination once yearly and no specific advice was given to them. Over 7 years follow up IHD mortality reduced 22% more intervention group.

out in USA on 12866 men aged 35-57

OSLO DIET /SMOKING INTERVENTION STUDY

1. 2. 3.

4.

5.

6.

Study began in 1973 16202 Norwegian men age 40-49 years were screened for CHD risk factors. Of these 1232 healthy normotensive men at risk (total cholesterol 290-379 and smoking) were selected for a 5 year randomized trial. The aim of the study was to determine whether lowering of serum lipids and cessation of smoking would reduce the incidence of first attack of CHD in males aged 40-49 years. The intervention was lowering cholesterol through dietary means (polyunsaturated fat in diet and cessation of smoking. At the end of the incidence of myocardial infarction was lower by 47% in the intervention group than in the control group.

The Lipid Research Clinics Coronary Primary 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 groups followed a moderate cholesterol-lowering diet.

the control group received a placebo for an average of 7.4 years.

Both The

treatment group had an 8.5 % and 12.5% reduction in total resulted in drug treatment of elevated serum cholesterol levels.

cholesterol than placebo. This resulted in 24% reduction in mortality.

This