Epidemiology of cardiovascular disorders and it's prevention.

A brief description about how cardiovascular disease impacts our lives.

1. Cardiovascular disorder

2. INTRODUCTION Cardiovascular diseases is a group of disorders that affects the heart and it’s vascular system. CVD is the leading cause of death all over the world. Most of the cardiovascular diseases are seen in countries with low to middle income because people do not have easy access to primary healthcare programs.

3. Types of cardiovascular disease Ischemic Heart Disease Hypertension Cerebrovascular disease(Stroke) Congenital Heart Disease Rheumatic Heart Disease.

4. DISEASE BURDEN GLOBALLY In 2019, an estimate of 17.9 million people died because of CVD, this represents 32% of all deaths in that year. An estimate of 7.4 million people died due to CHD 6.7 million people died due to stroke

5. DISEASE BURDEN IN INDIA In 2016 an estimate of 2.59 million people died due to CVD. Compared to other countries , INDIA suffers the highest loss in potentially productive years of life , due to deaths from CVD in people aged 35-64 years .

6. Why are Indians more affected?

7. Symptoms of heart attack Often there are no symptoms of the underlying disease of the blood vessels. Pain and discomfort in the centre of chest Pain and discomfort in the arms, left shoulder, elbows, jaw and back. Difficulty in breathing and shortness of breath Vomiting Feeling light headed and fainting. Becoming pale.

8. Internal factor External factor Congenital deformities Road traffic accident Heredity Depression Genetic factors Emotional trauma

9. Risk factor Inappropriate nutrition Insufficient physical activities Increase tobacco consumption Obesity High blood pressure Dyslipidaemia Diabetes Low cardio respiratory fitness

10. Prevention of risk factors End of tobacco use Reducing salt intake Consuming fruit and vegetables Regular physical activities Avoiding harmful use of alcohol Health policies Drug treatment

11. CORONARY HEART DISEASE

12. introduction Coronary heart disease (syn : ischemic 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.

13. MANIFESTATION OF CHD In case of coronary heart disease there is no apparent signs and symptoms but it manifests as following features at later stage: angina pectoris of effort myocardial infarction irregularities of the heart rhythm cardiac failure sudden death

14. DISEASE BURDEN GLOBALLY CHD is the leading cause of deaths from non-communicable disease(NCDS) in those under 20 years. Global CHD deaths in 2019 were 217,000. There were 129 countries with at least 50 deaths.

15. DISEASE BURDEN IN INDIA There is an considerable increase in prevalence of CHD in urban areas in India during the last decade. In urban areas the pooled estimate was 6.1% for males and 6.7% for females. Whereas in rural areas the estimate was 2.1% for males and 2.7% for females. Therefore it was assumed that mortality rates due to CHD in rural areas are expected to be the half of CCHD specific mortality rates in urban areas.

16. EPIDEMIOLOGY OF THE DISEASE No single agent can be pinpointed as the causative agent for coronary heart disease. The disease is caused by interaction of a variety of factors which is called web of causation .

17. RISK Factors NON- MODIFIABLE RISK FACTOR MODIFIABLE RISK FACTOR Age Cigarette smoking Sex High blood pressure Family history Diabetes Genetic history Obesity Personality Sedentary lifestyle Stress

18. PREVENTION AND CONTROL There are 4 levels of prevention that are used to tackle the problem. They are- Primordial level of prevention Primary level of prevention Secondary level of prevention Tertiary level of prevention

19. PRIMORDIAL LEVEL OF PREVENTION It involves preventing the emergence and spread of CHD risk factors and improving lifestyle so that further disruption of health does not occur. It deals with cessation of smoking, controlling blood pressure, and reducing body mass index by dietary changes and implementing regular physical activity.

20. PRIMARY LEVEL OF PREVENTION It deals with modifying the risk factors and minimizing the risk of such factors to develop into a full blown disease. Firstly, stress is the primary factor that needs to be tackled as it increases oxidation in the body and also increases the chances of atherosclerosis and it may also lead to other disorders such as hypertension and Diabetes mellitus.

21. Adults between 40 and 75 years of age should undergo 10-year atherosclerotic cardiovascular disease risk assessment before pharmaceutical therapy, such as antihypertensive therapy, statin, aspirin, and coronary artery calcium scanning, in selected individuals should be started. Adults should consume healthy diets such as fruits, vegetables, nuts, whole grain, lean vegetables, or animal protein and fish. Consumption of trans fat, red meat, processed meat, added sugars, saturated fat, sweetened beverages, and sodium should be reduced. Obese people should be advised to restrict caloric diet to maintain reduced weight.

22. People should perform 150 minutes/week of moderate intensity physical activity or 75 minutes/week of high intensity physical activity. Tobacco use should be stopped. Cigarette smokers should be encouraged/assisted in quitting smoking. Infrequent use of aspirin.

23. Control diet, exercise, and medicine if needed should be advised to diabetic patients. Statin should be used if serum LDL-C levels are ≥190 mg/dL and the individual is diabetics and has sufficient risk for CAD. Nonpharmacological intervention for adults with elevated blood pressure or hypertension is advised. Pharmacological therapy for hypertensive patients with a target of less than 130/80 is recommended.

24. Consumption of food containing high cholesterol (sausage, bacon, red meat, kidney liver, coconut oil, full fat dairy products, and palm oil) should be restricted. Food such as flaxseed that lowers the serum levels of TC and LDL-C and raises the levels of HDL-C should be advised. Use of whey protein that lowers TC and LDL-C should be useful. Use of grapefruit which contains resveratrol should be advised. Resveratrol reduces the serum levels of TC and LDL-C, raises HDL-C levels, inhibits expression of CRP, and lowers serum levels of AGE. Some foods (bean and legumes, whole grain, high fiber fruit, nuts, and chia seeds) that raise HDL-C should be recommended for the primary prevention of CAD.

25. SECONDARY LEVEL OF PREVENTION Secondary prevention must be seen as a continuation of primary prevention. It forms an important part of an overall strategy. The aim of secondary prevention is to prevent the recurrence and progression of CHD. Secondary prevention is a rapidly expanding field with much research in progress (e.g., drug trials, coronary surgery, use of pace makers).

26. Tertiary prevention It deals mainly with disability prevention and rehabilitation and is intended for the persons who have a preexisting case of CAD. The team comprises of general physician, cardiologist, cardio surgeon, dietician, physiotherapist and nurses. Medical rehabilitation includes PCI, CABG, pacemaker, defibrillator, and ventricular-assisted device. Physiotherapy management deals with educating the patient, tailoring an exercise plan, proper relaxation measures to maintain the heart health.

27. CONCLUSION Despite advances in treatment, the mortality of an acute heart attack is still high: among survivors, around 10 per cent in the first year, and thereafter 5 per cent yearly. Thus, prevention of risk factors is the main strategy to improve quality of life for CVD patients.

28. RHEUMATIC HEART DISEASE

29. INTRODUCTION Rheumatic fever (RF) and rheumatic heart disease (RHD) cannot be separated from an epidemiological point of view. Rheumatic fever is a febrile disease affecting connective tissues particularly in the throat by group A beta hemolytic streptococci. Although RF is not a communicable disease (streptococcal pharyngitis). Rheumatic fever often leads to RHD which is a crippling disease .

30. The consequences of RHD includes: Continuing damage to the heart Increasing disabilities, Repeated hospitalization and Premature death usually by the age of 35 years or even earlier. RHD is one of the most readily preventable chronic disease.

31. PROBLEM STATEMENT WORLD The incidence of rheumatic fever and rheumatic heart disease has not decreasing countries. Worldwide, there are over 15million cases of RHD with 500,000 new cases. During 2008,230,000 deaths from this disease occurred which is about 0.4 percent of total deaths.

32. In the number of affluent countries (North America, Western Europe and in Japan) the incidence of RF and the prevalence of and mortality from RHD have fallen during the last two decades, where the disease is now generally uncommon. Indicating that the fall in prevalence and incidence was associated with social and economic changes. INDIA In India RHD is prevalent in the range of 5-7 per thousand in 5-15 years age group and there are about 1 million RHD cases in India RDH constitute 20-30% of hospital admission due to CVD in India. Streptococcal infection are very common especially in children's living in under privileged conditions, and RF is reported to occur in 1-3 percent of those infections.

33. EPIDEMIOLOGICAL FACTOR 1 AGENT FACTOR The onset of RF is usually preceded by a streptococcal sore throat A streptococcus incriminated has the causative agent.It has been suggested that not all the strains of the group A streptococci lead to RF, it is belived that there might be some strains with “rheumatogenic potential ”. Recently the virues (coxsackie B4) has been suggested has a causative factor and streptococcus acting as a conditioning agent. (b)carriers: Carriers of group A streptococcus are frequent, example convalescent, transient and chronic carriers. 2. HOST AND ENVIRONMENT FACTORS AGE: RF is typically a disease of childhood and adolescents (5-15 years) although it is also occurred in adults(20% cases).

34. (b) SEX: The disease effect both the sexes equally but prognosis is worst for females than males ( c) IMMUNITY: An immunological basis for RF and RHD has be proposed the most prevalent concept is the toxic-immunological hypothesis. (d)SOCIOECONOMIC STATUS: RF is the social disease linked to poverty overcrowding poor housing conditions, inadequate health services, inadequate expertise is of health care providers and low awareness of disease in the community. (e) HIGH-RISK GROUPS: The school going children between 5-15 years; slum dwellers and those living in closed community.

35. AGENT 1.GROUP A STREPTOCOCCI 2.COXSACKIE B4 VIRUS IS ALSO THE CAUSATIVE FACTOR FOR RHD. 1.AGE:5-15YEARS 2.SEX 3.IMMUNITY 4.SOCIO-ECONOMIC STATUS 5.HIGH-RISK GROUP(5-15 YRS) 1.POVERTY 2.OVERCROWDING 3.INADEYATE HEALTH SERVICES 4.POOR HOUSING CONDITION 5.LOW LEVEL OF AWARENESS OF DISEASE IN COMMUNITY HOST ENVIRONMENT

36. CLINICAL FEATURES

37. CLINICAL FEATURES 1 . FEVER :It is present at the onset of acute illness and may be accompanied by profuse sweating .Last for about 12 weeks or longer and has tendency to reoccur. 2. POLYARTHRITIS :It occurs in 90% of cases the large joints like knees ankles elbows and wrist are involved uncommonly smaller joints of hands and feet may be involved 3. CARDITIS : Occurs in 60-70% of cases, all the layers of the heart – pericardium, myocardium and the heart valves – are involved . The involvement of heart is manifested by tachycardia, cardiac murmurs, cardiac enlargement, pericarditis and heart failure. 4. NODULES : Below the skin tend to appear four weeks after the onset of RF. . They are small, painless and non-tender. 5. BRAIN INVOLMENT: This manifest as abnormal jerky purposeless movements of arm, legs, and the body. 6. SKIN : Varies types of skin rash are know to occur.

38. DIAGNOSIS 2015 WHO criteria for the diagnosis of RF and RHD are based on reverse jones critera In the revised 2015 jones criteria, a low, medium and high-risk population was identified. Major criteria low risk population: clinical and/ or subclinical carditis AHA recommends that all the patients with suspected RF under go doppler eco- cardiographic examination, even if no clinical sign of carditis are present. In doubtful cases it is recommended that echo-cardiography is repeated Medium and high risk population: clinical or subclinical carditis and arthritis- monoarthritic or polyarthritis, possible also with polyarthralgia Minor criteria In low-risk population the parameters of inflammation and the level of fever where dedined precisely Medium and high-risk population- Monoarthralgia, also with defined parameters of inflammation and the level of fever.

39. PREVENTION: PRIMARY PREVENTION SECONDARY PREVENTION NON MEDICAL MEASURES EVALUATION

40. PRIMARY PREVENATION: AIM OF PRIMARY PREVENTION is to prevent first attack og RF, by identifying all the patients with streptococcal throughout infection and treating them with penicillin Vibal approach is to concentrate on high-risk groups such as school-age children. They should be kept under surveillance for streptococcal pharyngitis. Ideally a sore throat should be swabbed and cultured. A single intramuscular injections of 1.2million units of benzathine benzyl penicillin for adults and 6 lakhs unit for children is adequate or oral penicillin(penicillin V OR G) should be given for ten days. For the patients with allergy to penicillin, first generation cephalosporins that is cefadroxil or cefalexin is used the other drugs used azithromycin, erythromycin, clarithromycin .

41. SECONDARY PREVENTION It is a prevention of reoccurrences of RF and practice level approach, specially in developing countries. It consist of identifying those who have RF and giving them 1 intra muscular benzathine benzyl penicillin(1.2 million units) is added and (6 lakhs unit in children's) at interval of 3 week and this should be continued at least for years or until the child reaches 21 years whichever is later. For the patients with carditis ( mild mitral regurgitation or healed carditis) the treatment should continue for 10years after the last attack or at least until 40years of age whichever is longer NON MEDICAL MEASURES Non medical measures for the prevention or control of RF are related to improving living conditions, and breaking the poverty – disease – poverty cycle. Improvements in socio-economic condition(particularly better housing) will in the long term reduce in the incidence of RF.

42. EVALUATION 1. In the evaluation of program, the prevalence of RHD in school children from periodic survey's of random samples is probably is the best indicator 2. It is suggested that surveys should be carried out on samples (not individual) in the 6-14 years age group at 5- year intervals. 3. The recommended sample size is 20000-30000 children depending upon the expected prevalence.

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