EPID 624 Epidemiology of Chronic Diseases Sara Sigur Presentation Overview Background IncidencePrevalence Attributes associated with cardiovascular disease Costs Interventions Current and future research ID: 737969
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Epidemiology of Cardiovascular Disease
EPID 624 – Epidemiology of Chronic Diseases
Sara SigurSlide2
Presentation Overview
Background
Incidence/Prevalence
Attributes associated with cardiovascular disease
Costs
Interventions
Current and future researchSlide3
Background
Including incidence/prevalenceSlide4
Four Main Diseases
Coronary heart disease (CHD)
Heart failure (HF)
Stroke
Peripheral artery disease (PAD)Slide5
Coronary Heart Disease
also known as ischemic heart disease, coronary artery disease
attributed to reduced blood flow to the heart
most often caused by atherosclerosis
results in angina (chest pain), myocardial infarction (a.k.a. heart attack), and deathSlide6
Atherosclerosis
thickening of artery walls —> narrowing of arteries —> decreased blood flow —> increased risk of embolism (blood clot)
factors that contribute to development:
inflammation
calcification
deposit of fat/cholesterol
process begins in childhood; fetal factors may be involvedSlide7
Incidence of CHD
“Every 43 seconds, someone in the United States has a heart attack” - Center for Disease Control
Every year there are approximately 1.2 million new or recurrent heart attacks in the U.S. Slide8
Prevalence of CHD
An estimated 80 million Americans have one or more CVD
CHD accounts for 52% of CVD deaths
death rates from CHD peaked in 1963 and have steadily been decreasing since 1968
26% decline in death rates from CVD overall from 1995-2005Slide9
Heart Failure
inability of either left or right ventricle to properly fill with or eject blood secondary to damaged or weakened heart muscles
shortness of breath + fatigue —> decreased exercise tolerance + fluid retention —> pulmonary and peripheral edema —> decreased quality of life
left vs right heart failure Slide10
Incidence and Prevalence of HF
Approximately 25% of men and 45% of women will develop HF within 6 years of having a heart attack
HF is the one CVD that is increasing in incidence, prevalence, and mortality
CVD is the leading cause of disability in the U.S.Slide11
Attributes associated with CVDSlide12
Race/Ethnicity
- CVD - leading cause of death in U.S. for whites, blacks, and American Indians
- Age-adjusted CVD mortality rates (per 100,000)
438 for African American men
325 for white men
319 for AA women
230 for white women
- Hispanics and Asian Americans appear to be at lower risk of heart disease and stroke mortality than whites
http://www.cdc.gov/heartdisease/family_history.htmSlide13
Age
Mortality greater among older adults
increases independent of other known risk factors
55% of heart attacks are in those 65+; 85% of deaths from MI are in those 65+
CHD incidence rates in women after menopause are 2-3x higher than those women pre-menopausal of the
same ageSlide14
Sex
Age-adjusted mortality 45% higher in men
Still leading cause of death in U.S. women
CHD incidence for women lags behind men by 10 years Slide15Slide16
Geography
http://www.cdc.gov/dhdsp/maps/national_maps/hd_hospitalization_all.htmSlide17
http://www.cdc.gov/dhdsp/maps/national_maps/hd65_all.htmSlide18
http://www.cdc.gov/dhdsp/maps/sd_poverty.htmSlide19
Socioeconomic Status
CHD incidence and mortality higher in those of lower SES
so far, greatest decline in CHD mortality has been seen in white men/women with the highest levels of education/income
living in “deprived” neighborhoods linked with increased risk factorsSlide20
Global Perspective
Mortality rates remain higher in U.S. than many other industrialized nations
2020 Projections:
Latin America, the Middle East, and sub-Saharan Africa will have 3x the occurrence of heart disease from 1990-2020
rates in developing countries will increase 120% for women, 137% for menSlide21
Adverse Behaviors
Poor diet
Lack of physical activity
Smoking
Alcohol consumption
All which can contribute to…obesity, diabetes, high blood pressure, high cholesterolSlide22
Cost
$151.6 billion = 2004 estimated cost of medical care, lost earnings, and lost productivity
$475 billion = 2009 estimated direct and indirect costs of CVD per AHA
HF specifically - high hospitalization rates and poor prognosis, strain on Medicare
3 most prominent factors influencing economic burden:
revascularization procedures
hospital care
prescription medications
http://www.commed.vcu.edu/Chronic_Disease/Heart/prevstrat_21Cent.pdfSlide23
http://www.commed.vcu.edu/Chronic_Disease/2010/orprevhtataglance.pdfSlide24
Interventions
Primary, secondary, tertiary, community-levelSlide25
Primary Prevention
Control of modifiable risk factors
decrease cholesterol/systolic BP/smoking/physical inactivity
recent efforts in this area have accounted for 44% decline in CHD mortality
efforts partially offset by increases in BMI and diabetes
Environmental changes
Million Hearts Initiative
http://www.commed.vcu.edu/Chronic_Disease/Heart/2012/cvsnatpolicy.pdfSlide26
http://millionhearts.hhs.gov/about-million-hearts/million-hearts.htmlSlide27
Secondary Prevention
Screening for high blood pressure/cholesterol
Electrocardiograms for high risk individualsSlide28
Tertiary Prevention
Revascularization - stents, coronary artery bypass grafts
Cardiac rehab - prevention of complications through diet, exercise, weight control, and smoking cessation
Medications - statins, diuretics, beta blockers
Mechanical assist devices - pacemakers, LVADSlide29
Community-level
use education and environmental changes to promote positive lifestyle and behavior changes
North Karelia Project
began in 1972
studied risk factor interventions
interventions directed at the media and food producers/distributors Slide30
http://www.commed.vcu.edu/Chronic_Disease/Heart/2014/commguideAHA2013.pdfSlide31
Healthy People 2020
Many goals related to heart disease, including:
reduce proportion of adults with hypertension (from 29.9 to 26.9%)
reduce proportion of adults with high total blood cholesterol levels (from 15.0 to 13.5%)
https://www.healthypeople.gov/2020/topics-objectives/topic/heart-disease-and-stroke/objectives?topicId=21Slide32
Research
Current/Future/Issues Slide33
Framingham Heart Study
began in 1948, conducted by National Heart Institute
primary aim: identify factors and characteristics contributing to CVD
enrolled ~5,200 men and women with no overt signs/symptoms of disease, examining them every two years
allowed for the identification of key risk factors
http://www.framinghamheartstudy.org/about-fhs/history.phpSlide34
Gene/Stem Cell Therapy
Interest in using both therapies to aid in repair of damaged tissue
controversial
needs further study in humans
http://www.commed.vcu.edu/Chronic_Disease/Heart/2012/cvschallenges2011.pdfSlide35
Link Between Cholesterol and CVD
Landmark study published in 1966
Looked at link between HDL and heart disease
Importance of looking to past research to advance current knowledge
http://www.commed.vcu.edu/Chronic_Disease/Heart/revisiitingpastrsch.pdfSlide36
Cholesterol in Children
Report from National Center for Health Statistics analyzing data from NHANES
Children 6-19 years old
Key findings:
Approximately 1/5 children and adolescents had at least one abnormal cholesterol measure (high total cholesterol, low HDL cholesterol, or high non-HDL cholesterol)
Those who were obese had 5x prevalence of low HDL levels compared to normal weight
American Academy of Pediatrics recommends monitoring cholesterol in all children
Long-term monitoring may inform public health interventions and prevent CVD as an adult
http://www.cdc.gov/nchs/data/databriefs/db228.htmSlide37
Diet Considerations
U.S. Dietary Guidelines Advisory Committee released 2015
Dietary Guidelines
recommendations
May see dietary cholesterol removed from list of “nutrients of concerns”
Eliminate a limit on total fat consumption
type more important that quantity
http://www.commed.vcu.edu/Chronic_Disease/Heart/2016/BMJEditFoodObj.pdfSlide38
Gaps in Knowledge
Role of genetics - inflammatory biomarkers and signaling pathways
Public health implementation science - role of social networks, transportation, media, etc.
more community-based studies needed
Population-based prevention research
especially for minority populations, women/children
http://www.commed.vcu.edu/Chronic_Disease/Heart/2012/cvsnatpolicy.pdfSlide39
Gaps, cont.
Understanding of causes of HF is still not well known; prognosis still very poor
Optimal range for BP meds and lipid-lowering meds still unclear
too lenient vs too aggressive
http://www.commed.vcu.edu/Chronic_Disease/Heart/2012/cvschallenges2011.pdfSlide40
Other Road Blocks
Delayed clinical implementation
ability to understand applicability of new findings/technologies
beta blockers - routinely prescribed 25 years after publication of definitive randomized trials on their benefits for post MI survivors
COST
of research itself - difficult and expensive to conduct large-scale randomized trials
of different primary prevention methods - prescribing more meds does not seem to be cost effective
Current agricultural policies
http://www.commed.vcu.edu/Chronic_Disease/Heart/2012/cvschallenges2011.pdf
http://www.commed.vcu.edu/Chronic_Disease/Heart/2012/cvsnatpolicy.pdfSlide41
http://www.commed.vcu.edu/Chronic_Disease/Heart/2015/altresearchstrat..pdfSlide42
References
Remington, P. L.,
Brownson
, R. C., & Wegner, M. V. (2010).
Chronic disease epidemiology and control
. Washington, DC: American Public Health Association.Slide43
Questions?