CORONARY HEART DISEASE CHD lecture .pptx

Coronary heart disease (syn : ischaemic heart disease)
has been defined as ".impairment of heart function due to
inadequate blood flow to the heart compared to its needs,
caused by obstructive changes in the coronary circulation to
the heart" . It is the cause of 25-30 per cent of deaths in
most industrialized countries. The WHO has drawn attention
to the fact that CHO is our modern "epidemic'', i.e., a
disease that affects populations, not an unavoidable
attribute of ageing. CHO may manifest itself in many
presentations :
angina pectoris of effort
myocardial infarction
irregularities of the heart
cardiac failure
sudden death.
Myocardial infarction is specific to CHO; angina pectoris
and sudden death are not. Rheumatic heart disease
and cardiomyopathy are potential sources of diagnostic
confusion . The natural history of CHO is very variable.
Death may occur in the first episode or after a long history of
disease. The aetiology of CHD is multifactorial. Apart from the
obvious ones such as increasing age and male sex, studies
have identified several important "risk" factors (i.e., factors
that make the occurrence of the disease more probable).
Some of the risk factors are modifiable, others immutable
. Presence of any one of the risk factors places an
individual in a high-risk category for developing CHD. The
greater the number of risk factors present, the more likely
one is to develop CHD.

1. THE CARDIOVASCULAR DISEASES EPIDEMIOLOGY, PREVENTION AND CONTROL DR HALA BASHIR HASHMI COMMUNITY MEDICINE

2. ·Disease Prevention Models ·Primordial and primary prevention ·Health Promotion ·Behavioral Change Intervention ·Secondary & Tertiary Prevention · ·Risk factor assessment of CVS diseases WHAT WILL YOU LEARN?

3. CHD is linked to human susceptibility, unfavorable environments, and mass health behaviors. Cardiovascular diseases (CVD) comprise of a group of diseases of the heart and the vascular system. ischaemic heart disease (IHD) hypertension cerebrovascular disease (stroke) congenital heart disease. Rheumatic heart disease (RHD) WHAT ARE CARDIOVASCULAR DISEASES

4. epidemiology Non-communicable Diseases (NCDs): Responsible for 36 million deaths annually. Cardiovascular Diseases (CVDs): Account for 17 million deaths, over half of NCD deaths. Middle-aged Adults: Over one-third of CVD deaths occur in this group. Developed Countries: Heart diseases and stroke are the leading causes of death for adults. Developing Countries: CVDs are also leading causes, responsible for one-third of all deaths. PROBLEM STATEMENT

5. epidemiology Disability-Adjusted Life Years (DALYs): CVDs account for 25% of DALYs lost due to NCDs in SEAR countries. Ischemic Heart Disease (IHD): 40% of DALYs lost. Cerebrovascular Diseases: 19% of DALYs lost. Rheumatic Heart Disease: 6% of DALYs lost. Inflammatory Heart Diseases: 6% of DALYs lost. Other Conditions: 29% of DALYs lost. PROBLEM STATEMENT

6. epidemiology Urban vs. Rural Incidence: Higher in urban areas due to risk factors like tobacco use, lack of physical activity, unhealthy diet, and obesity. Early Age of CVD Deaths: A concern in developing countries. Decline in Industrialized Countries: Due to successful primary prevention and treatment. Emerging Epidemic in Middle and Low-Income Countries: These countries can benefit from primary prevention strategies. PROBLEM STATEMENT

7. Behavioural risk factors RISK FACTORS FOR CVD Tobacco Use Inappropriate Diet: High in saturated fats, salt, and refined carbohydrates; low in vegetables and fruits. Physical Inactivity

8. BIOLOGICAL RISK FACTORS RISK FACTORS FOR CVD Overweight and Central Obesity High Blood Pressure Dyslipidemia: High cholesterol levels. Diabetes Low Cardio-Respiratory Fitness

9. NUTRITIONAL FACTORS RISK FACTORS FOR CVD High Cholesterol: Persistently high levels can lead to cardiac events. Unhealthy Dietary Practices: High consumption of saturated fats, salt, refined carbohydrates; low consumption of vegetables and fruits.

10. PROTECTIVE FACTORS RISK FACTORS FOR CVD Regular Physical Activity Consumption of Linoleic Acid, Fish and Fish Oils (EPA and DHA), Vegetables and Fruits, Potassium, Wholegrain Cereals, Nuts (unsalted), Plant Sterols/Stanols, Folate, Flavonoids

11. OTHER RISK FACTORS RISK FACTORS FOR CVD High Sodium Intake High Alcohol Intake (for stroke) Impaired Fetal Nutrition

12. MODIFIABLE RISK FACTORS NON MODIFIABLE RISK FACTORS LESSON CHECK :

13. INTERVENTION TO REDUCE CARDIOVASCULAR DISEASE BURDEN CVD PRIMARY PREVENTION:. A) POPULATION WIDE INTERVENTION B) INDIVIDUAL LEVEL INTERVENTION POPULATION WIDE INTERVENTION: comprehensive tobacco control policies reduce intake of food with high salt and sugar content building walking and cycling paths strategies to reduce harmful intake of alcohol providing healthy school meals 1

14. INTERVENTION TO REDUCE CARDIOVASCULAR DISEASE BURDEN CVD PRIMARY PREVENTION:. A) POPULATION WIDE INTERVENTION B) INDIVIDUAL LEVEL INTERVENTION INDIVIDUAL LEVEL INTERVENTION: high risk population management of each case at primary care center 1

15. INTERVENTION TO REDUCE CARDIOVASCULAR DISEASE BURDEN CVD SECONDARY PREVENTION:. Aspirin beta blockers angiotensin converting enzyme inhibitors statin 2

16. CORONARY HEART DISEASE CVD CHD, also known as ischemic heart disease, is the impairment of heart function due to inadequate blood flow caused by obstructive changes in the coronary arteries. .

17. CORONARY HEART DISEASE CVD Mortality Rate: Responsible for 25-30% of deaths in most industrialized countries. WHO Statement : CHD is considered a modern “epidemic” affecting populations, not just an attribute of aging. Manifestations of CHD: Angina pectoris of effort Myocardial infarction (specific to CHD) Irregularities of the heart Cardiac failure. .

18. EPIDEMIOLOGY MEASURING THE BURDEN OF DISEASE LOSS OF LIFE EXPECTANCY INCIDENCE RATE PREVALENCE RATE CASE FATALITY RATE PROPOTIONAL MORTALITY RATIO AGE SPECIFIC DEATH RATES

19. International Variations: CHD causes 7.2 million deaths, 12.8% of total deaths worldwide. Mortality rates vary widely across different regions Different Onset Times: United States: Epidemic began in early 1920s. Britain: Epidemic began in the 1930s. Several European Countries: Epidemic began later. Developing Countries: Currently catching up. I EPIDEMICITY

20. Decline in Mortality: United States: Steady decline evident by 1968; 25% fall in mortality by 1980. Other Countries: Substantial declines in Australia, Canada, and New Zealand. Attributed Factors: Changes in lifestyles and related risk factors (e.g., diet, serum cholesterol, cigarette use, exercise habits). Better control of hypertension. . I EPIDEMICITY

21. WHO MONICA Project: Multinational monitoring of trends and determinants in cardiovascular diseases. 41 centers in 26 countries participated, planned for 10 years ending in 1994. Social Class Shift: Initially a disease of higher social classes in affluent societies. Now, a strong inverse relation between social class and CHD in developed countries. EPIDEMICITY

22. THERE ARE TWO BROAD CLASSIFICATION: RISK FACTORS NON MODIFIABLE RISK FACTORS AGE SEX FAMILY HISTORY GENETIC FACTORS PERSONALITY MODIFIABLE CIGARRETTE SMOKING HIGH BLOOD PRESSUE SERUM CHOLESTEROL DIABETES OBESITY SEDENTARY HABBITS STREES

23. SMOKING Risk of death from CHD decreases significantly after stopping smoking. Substantial risk decline within one year of cessation. After 10-20 years, risk is similar to that of non-smokers. For those with a myocardial infarction, the risk of a fatal recurrence may be reduced by 50% after RISK FACTORS

24. HYPERTENTION The blood pressure is the single most useful test for identifying individuals at a high risk of developing CHD. Hypertension accelerates the atherosclerotic process, especially if hyperlipidaemia is also present and contributes importantly to CHD. RISK FACTORS

25. HYPERCHOLESTREMIA Serum cholesterol was one of the factors which carried an increased risk for the development of myocardial infarction Low-density lipoprotein (LOL) cholesterol that is most directly associated with CHO High-density lipoprotein (HOL) cholesterol is protective against the development of CHO Total "cholesterol/HOL ratio" Apolipoprotein-A-1 (the major HOL protein) and apolipoprotein-B (the major LOL protein) are better predictors of CHO than HOL cholesterol or LOL cholesterol respectively. RISK FACTORS

26. Diabetes : The risk of CHO is 2-3 times higher in diabetics than in non-diabetics. Genetic factors : A family history of CHO is known to increase the risk of premature death. Physical activity : Sedentary life-style is associated with a greater risk of the development of early CHO. OTHER RISK FACTORS

27. OTHER RISK FACTORS HORMONES: It has been hypothesized that hyperestrogenemia may be the common underlying factor that leads both to atherosclerosis and its complications such as CHO, stroke and peripheral vascular disease. Type A personality Alcohol consumption oral contraceptives

28. In the 1960s the issue was whether CHD could be prevented or not. Studies were launched, reported and debated. The accumulated evidence led to a broad consensus of expert opinion that CHD is preventable . WHO Expert Committee recommended the following strategies : Population strategy High risk strategy Secondary prevention. prevention OF CHD

29. IREVENTION IN WHOLE POPULATION PRIMORDIAL PREVENTION IDENTIFYING RISK SPECIFIC ADVICE POPULATION STRATEGY Same as those already set out in the above sections, e.g., cessation of smoking, control of hypertension and diabetes, healthy nutrition, exercise promotion BETA BLOCKERS HIGH RISK STRATEGY WHO STRATEGY PREVENTION SECONDARY PREVENTION

30. Consumption of saturated fats must be limited to less than 10 per cent of total energy intake some of the reduction in saturated fat may be made up by mono and poly-unsaturated fats a reduction of dietary cholesterol to below 100 mg per 1000 kcal per day an increase in complex carbohydrate consumption {i.e., vegetables, fruits, whole grains and legumes) avoidance of alcohol consumption; reduction of salt intake to 5 g daily or less. Dietary changes Specific interventions POPULATION STRATEGY

31. To achieve the goal of a smoke-free society, a comprehensive health programme would be required which includes effective information and education activities, legislative restrictions, fiscal measures and smoking cessation programmes. SMOKING Specific interventions POPULATION STRATEGY

32. The goal of the population approach to high blood pressure would thus be to reduce mean population blood pressure levels. This involves a multifactorial approach based on a "prudent diet" BLODD PRESSURE Specific interventions POPULATION STRATEGY

33. Regular physical activity should be a part of normal daily life. It is particularly important to encourage children to take up physical activities that they can continue throughout their lives PHYSICAL ACTIVITY Specific interventions POPULATION STRATEGY

34. It involves preventing the emergence and spread of CHD risk factors and life-styles that have not yet appeared or become endemic. LIFE STYLE MODIFICATION PRIMORDIAL PREVENTION POPULATION STRATEGY

35. The Multiple Risk Factor Intervention Trial (MRFIT) in the US The Stanford Heart Disease Prevention Programme in California The North Kerelia Project in Finland MULTIFACTORAL APPROACH PRIMORDIAL PREVENTION POPULATION STRATEGY

36. Identifying risk Specific advise HIGH RISK STRATEGY Several well planned high-risk intervention studies (e.g., Oslo Heart Study, Lipid Research Clinics Study, in US have shown that it is feasible to reduce the CHO risk factors.

37. The aim of secondary prevention is to prevent the recurrence and progression of CHD. SECONDARY PREVENTION smoking cessation, controlling hypertension and diabetes, healthy nutrition, and exercise. Beta-blockers have shown promising results, reducing CHO mortality by 25% in patients with a prior infarct. Despite treatment advances, acute heart attack mortality remains high, with significant delays in hospital arrival contributing to the issue.

38. SECONDARY PREVENTION TRIALS Secondary prevention trials are aimed at preventing a subsequent coronary attack or sudden death. A wide range of clinical trials have been performed with four main groups of drugs - anti-coagulants, lipid-lowering agents (e.g., clofibrate), anti-thrombotic agents (e.g., aspirin) and beta blockers. The most promising results to date have come from beta blockers. In general the above studies and similar others show that it is feasible through well-planned intervention programmes to reduce the risk factors in the populations studied. The primary and secondary prevention studies promise at present to be the main contribu

39. Since 1951, the Framingham Study has been crucial in identifying CHO risk factors like elevated serum cholesterol, smoking, hypertension, and sedentary habits. Key interventions include reducing cholesterol, quitting smoking, controlling hypertension, and promoting physical activity. Both single and multifactorial risk factor trials are essential. Notable intervention trials include the Stanford Heart Disease Prevention Programme, North Kerelia Project, Oslo Study, MRFIT, and Lipid Research Clinics Study. RISK FACTOR INTERVENTION TRIAL

40. The Stanford-Three-Community Study A 1972 field experiment in northern California showed that intensive community health education campaigns significantly reduced cardiovascular disease risk by 23-28% compared to a control town. THE NORTH KERILA PROJECT Has four components: plasma, red blood cell, white blood cell and platelets Carries oxygen, nutrients and wastes MRFIT Has three types: arteries, veins and capillaries Serve as channels for the blood RISK FACTORS INTERVENTIONAL TRIALS

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