Idea Transcript
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38 Ten-Day Seminar on the
Epidemiology and Prevention of Cardiovascular Disease July 22–August 3, 2012 Granlibakken Conference Center Tahoe City, California Sponsored by the American Heart Association’s Council on Epidemiology and Prevention, the Centers for Disease Control and Prevention, and the National Association of Chronic Disease Directors 1
General Information Course Description The primary goal of the seminar is to provide an intensive introduction to the epidemiology and prevention of major cardiovascular diseases for qualified health professionals planning careers in research, teaching or practice in this area. A select faculty of epidemiologists and biostatisticians and prevention researchers will present discussions, lectures and laboratory and tutorial sessions illustrating basic principles of cardiovascular disease epidemiology and prevention and their applications. There will be extensive group participation. Target Audience Physicians and Nurses with a focus in research, teaching or practice in Cardiovascular Disease.
Learning Objectives
At the conclusion of the program, healthcare professionals, researchers and public health practitioners should be able to: •
•
Incorporate into research, teaching and/or practice, an increased understanding of the nature of cardiovascular health (CVH) and cardiovascular diseases (CVD), especially coronary heart disease and stroke, and epidemiologic approaches to the investigation of these diseases. Improve research productivity by applying the major epidemiologic approaches to the investigation of current research questions through collaborative, multidisciplinary development of research proposals.
•
Incorporate into grant writing, publications, teaching and practice an enhanced ability to critically evaluate epidemiologic evidence.
•
Compare and contrast study designs required to test specific hypotheses related to the distribution, risk factors and prognosis of cardiovascular disease in the population
•
Identify federal and foundation grant resources for carrying out cardiovascular disease epidemiology research
•
Increase activity in relevant cardiovascular health policy advocacy by acting on improved ability to recognize and evaluate the epidemiologic basis for policy and practice in CVD prevention and CVH promotion.
Continuing Medical Education Accreditation Physicians This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of the American Heart Association and the National Association of Chronic Disease Directors. The American Heart Association is accredited by the ACCME to provide continuing medical education for physicians. All persons who develop and/or control educational content in CME/CE activities sponsored by the American Heart Association will disclose to the audience all financial relationships with any commercial supporters of this activity as well as with other commercial interests whose lines of business are related to the CME/CE-certified content of this activity. In addition, presenters will disclose unlabeled/unapproved uses of drugs or devices discussed in their presentations. Such disclosures will be made in writing in course presentation materials. Continuing Education Accreditation - Nurses American Heart Association is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
Disclosure
All faculty participating in CME/CE activities sponsored by The American Heart Association will disclose to the audience (1) significant financial relationships with the manufacturer(s) of products from the commercial supporter(s) and/or the manufacturer(s) of products or devices discussed in their presentation, and (2) unlabeled/unapproved uses of drugs or devices discussed in their presentation. Such disclosures will be made in writing in course presentation materials.
Content Validation
The AHA is responsible for validating the clinical content of its CME activities. All recommendations involving clinical medicine are based on evidence that is accepted within the medical profession as adequate justification for their indications/contraindications in patient care. All scientific research referred to, reported or used in support or justification of a patient care recommendation conforms to the generally
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accepted standards of experimental design, data collection and analysis,
Disclaimer
The American Heart Association gratefully acknowledges the educational grants provided for this program by:
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The 38 Ten-Day Seminar on the Epidemiology and Prevention of Cardiovascular Disease is a scientific and educational conference for the purpose of exchanging and discussing research results and scientific developments in the field of cardiovascular disease. Accordingly, the American Heart Association cannot and does not offer any assurance or warranty of the accuracy, truthfulness, or originality of the information presented at the conference.
Seminar Financial Support
The Seminar is administered by the American Heart Association’s Council on Epidemiology and Prevention and the Wake Forest University School of Medicine. Financial support is provided by the American Heart Association, grants from the Centers for Disease Control and Prevention and the National Association of Chronic Disease Directors.
ADA Statement
If you require auxiliary aids or services as identified in the Americans with Disabilities Act, please note your needs at Registration. We encourage participation by all individuals. If you have a disability, advance notification of any special needs will help us serve you better.
The American Heart Association also gratefully acknowledges the following companies for their support:
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The American Heart Association is a national voluntary health agency whose mission is: “Building healthier lives, free of cardiovascular diseases and stroke.”
Faculty Cheryl A. M. Anderson, PhD, MPH, MS, FAHA Johns Hopkins University, Baltimore, MD
Mahasin S. Mujahid, PhD, University of California, Berkeley, Berkeley, CA
Sonia Angell, MD, MPH Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA
James S. Pankow, MD, MPH, FAHA, University of Minnesota, Minneapolis, MN
Alain G. Bertoni, MD, MPH, FAHA, Wake Forest University Health Sciences, Winston-Salem, NC
Pamela Peterson, MD, Denver Health Medical Center, Denver, CO
Mercedes Carnethon, PhD, FAHA, Northwestern University Feinberg School of Medicine, Chicago, IL Michael H. Criqui, MD, MPH, FAHA, University of California, San Diego, School of Medicine, La Jolla, CA Henry A. Feldman, PhD, Children’s Hospital Boston, Harvard Medical School, Boston, MA Janet E. Fulton, PhD, Centers for Disease Control and Prevention, Atlanta, GA David C. Goff Jr., MD, PhD, FAHA, FACP Colorado School of Public Health Denver, CO Kathleen L. Grady, PhD, APN, FAAN, FAHA Northwestern University, Feinberg School of Medicine, Chicago, IL Philip Greenland, MD, NUCATS Institute, Chicago, IL George Howard, DrPH, FAHA, University of Alabama at Birmingham, Birmingham, AL Robert M. Kaplan, PhD, National Institutes of Health, Bethesda, MD Darwin R. Labarthe, MD, MPH, PhD, FAHA, Northwestern University, Feinberg School of Medicine, Chicago, IL Cora E. Lewis, MD, MSPH, FACP, FAHA, University of Alabama at Birmingham, Birmingham, AL
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38th Ten-Day Seminar on the Epidemiology and Prevention of Cardiovascular Disease July 22 – August 3, 2012
Sunday, July 22 4:00 PM—5:00 PM Faculty Meeting 6:30 PM Opening Reception/Banquet Program Orientation
Monday, July 23 8:30 AM—9:30 AM Epidemic Processes (Goff) 9:30 – 10:00 AM Refreshment Break
10:00 AM—11:30 AM Case Comparison Study (Groups) 11:30 AM—1:30 PM Lunch on your own 1:30 PM—2:30 PM Introduction to Genetics (Pankow) 2:30 PM—3:30 PM Biostatistics Review 3 (Feldman) 3:30 – 4:00 PM Refreshment Break 4:00 PM—5:00 PM Physical Activity and CVH (Fulton)
10:00 AM—11:30 AM Population Surveys (Groups)
5:00 PM—6:00 PM Obesity and CVH (Lewis)
11:30 AM—1:30 PM Lunch on your own
Group Dinner
1:30 PM—2:30 PM Biostatistics Review 1 (Feldman)
Wednesday, July 25
2:30 PM—3:30 PM Biostatistics Review 2 (Feldman) 3:30 – 4:00 PM Refreshment Break 4:00 PM—5:00 PM Epidemiologic Approaches (Goff) 5:00 PM—6:00 PM Diet and CVH (Anderson) Group Dinner
8:30 AM—9:30 AM Blood Pressure and CVH (Goff) 9:30 – 10:00 AM Refreshment Break 10:00 AM—11:30 AM Cohort Studies (Groups) 11:30 AM—1:30 PM Special Lunch Arrangements 1:30 PM—3:30 PM Special Event 3:30 PM – 4:00 PM Refreshment Break
Tuesday, July 24 8:30 AM—9:30 AM The A, B, C and D’s of Epidemiology (Goff) 9:30 – 10:00 AM Refreshment Break
4:00 PM—5:00 PM Dyslipidemia and CVH (Criqui) 5:00 PM—6:00 PM Diabetes and CVH (Carnethon) Group Dinner
5
Thursday, July 26
Saturday, July 28
8:30 AM—9:30 AM Genetics and CVH (Pankow)
8:30 AM—12:00 PM Biases/Confounding/Causality/Policy (Bertoni/Criqui/Labarthe/Angell)
9:30 – 10:00 AM Refreshment Break
10:00 AM—10:30 AM Refreshment Break
10:00 AM—11:30 AM Clinical Trial Study (Groups)
12:00 PM Close
11:30 AM—1:30 PM Lunch on your own
Sunday, July 29
1:30 PM—3:30 PM Reading/Consultation
Optional Group Outing
3:30 – 4:00 PM Refreshment Break 4:00 PM—5:00 PM The Social and Cultural Basis of CVH (Mujahid) 5:00 PM—6:00 PM Alcohol and CVH (Criqui) Group Dinner
Friday, July 27 8:30 AM—9:30 AM Evaluating New Biomarkers for Cardiovascular Disease (Lewis)
Monday, July 30 8:30 AM—9:30 AM Multivariate Analysis 1 (Howard) 9:30 – 10:00 AM Refreshment Break 10:00 AM—11:30 AM Policy Study (Groups) 11:30 AM—1:30 PM Lunch on your own 1:30 PM—3:30 PM Reading/Consultation
9:30 – 10:00 AM Refreshment Break
3:30 – 4:00 PM Refreshment Break
10:00 AM—11:30 AM Community Intervention Study (Groups)
4:00 PM—5:00 PM Quality of Care and Outcomes Research (Peterson)
11:30 AM—1:30 PM Lunch on your own
5:00 PM—6:00 PM Quality of Life Research in CVH (Grady)
1:30 PM—3:30 PM Reading/Consultation
Group Dinner
3:30 – 4:00 PM Refreshment Break
Tuesday, July 31
4:00 PM—5:00 PM Stroke (Howard) 5:00 PM—6:00 PM PAD (Criqui) Special Dinner Arrangements
8:30 AM—9:30 AM Multivariate Analysis 2 (Howard) 9:30 – 10:00 Refreshment Break 10:00 AM—11:45 AM Study Design–1 (Groups)
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11:45 AM—1:00 PM Special Lunch Arrangements 1:00 PM—2:00 PM Concepts of Prevention (Greenland) 2:00 PM—3:00 PM Individual Intervention in Practice (Bertoni)
3:30 – 4:00 PM Refreshment Break 4:00 PM—5:00 PM Research Career Development (Greenland) 5:00 PM—6:00 PM Comparative Effectiveness Research (Kaplan)
3:30 PM—6:00 PM Special Event
Group Dinner
6:00 PM Special Dinner Arrangements
Friday, August 3
Wednesday, August 1
8:30 AM—10:00 AM CV Health Policy. Federal and State and Local (Labarthe)
8:30 AM—9:30 AM Sample Size and Power (Feldman) 9:30 – 10:00 AM Refreshment Break 10:00 AM—11:30 AM Study Design–2 (Groups) 11:30 AM—1:30 PM Lunch on your own 1:30 PM—3:30 PM Reading/Consultation 3:30 – 4:00 PM Refreshment Break 4:00 PM—5:00 PM Population Intervention in Practice (Angell) 5:00 PM—6:00 PM Culturally Tailored Interventions (Anderson) Group Dinner
Thursday, August 2
10:00 – 10:30 AM Refreshment Break 10:30 AM—11:30 AM Study Design–4 (Groups) 11:30 AM—1:00 PM Special Lunch Arrangements 1:00 PM—3:30 PM Presentation and Critique of Study Designs (All) 3:30 – 4:00 PM Refreshment Break 4:00 PM—4:30 PM The AHA and You (All) 4:30 PM—5:00 PM Evaluation (All) 5:00 PM—6:00 PM Faculty Meeting 6:30 PM Reception 7:30 PM Closing Banquet
8:30 AM—9:30 AM Chronic Heart Failure (Peterson) 9:30 – 10:00 AM Refreshment Break 10:00 AM—11:30 AM Study Design–3 (Groups) 11:30 AM—1:30 PM Lunch on your own 1:30 PM—3:30 PM Reading/Consultation
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38 Ten-Day Seminar on the Epidemiology and Prevention of Cardiovascular Disease July 22 – August 3, 2012 Date
AM 1 (8:30-9:30)
AM 2 (10:00-11:30)
Lunch (11:30-1:30)
PM 1 (1:30-2:30)
PM 2 (2:30-3:30)
PM 3 (4:00-5:00)
PM 4 (5:00-6:00)
Faculty Meeting
Evening
July 22
(Sun)
A, B
23
(Mon)
Epidemic Processes (Goff)
Population Surveys (Groups)
(on your own)
Biostatistics Review – 1 (Feldman)
Biostatistics Review – 2 (Feldman)
Epidemiologic Approaches (Goff)
Diet and CVH (Anderson)
D
24
(Tue)
The A, B, C, & D's of Epidemiology (Goff)
Case-Comparison (Groups)
(on your own)
Intro to Genetics
Biostatistics Review – 3 (Feldman)
Physical Activity and CVH (Fulton)
Obesity and CVH
(Pankow)
D
(Lewis)
25
(Wed)
Blood Pressure & CVH (Goff)
Cohort Studies (Groups)
Special event
Special event
Special event
Dyslipidemia & CVH (Criqui)
Diabetes & CVH (Carnethon)
D
26
(Thu)
Genetics and CVH (Pankow)
Clinical Trials (Groups)
(on your own)
Reading/ Consultation
Reading/ Consultation
Alcohol & CVH (Criqui)
D
27
(Fri)
Evaluating New Biomarkers for Cardiovascular Disease (Lewis)
The Social & Cultural Basis of CVH (Mujahid)
Community Intervention (Groups)
(on your own)
Reading/ Consultation
Reading/ Consultation
Stroke
PAD (Criqui)
C
28
(Sat)
29
(Sun)
30
(Mon)
Multivariate Analysis I (Howard)
Policy (Groups)
(on your own)
Reading/ Consultation
Reading/ Consultation
Quality of Care and Outcomes Research (Peterson)
Quality of Life Research (Grady)
D
31
(Tue)
Multivariate Analysis 2 (Howard)
Study Design – 1 (Groups)
F (11:45 –1:00)
Concepts of Prevention
Individual Intervention in Practice (2:00-3:00) (Bertoni)
Special event
Special event
C
(3:30-6:00)
(3:30-6:00)
(on your own)
Reading/ Consultation
Reading/ Consultation
Population Intervention in Practice (Angell)
Culturally Tailored Interventions
Research Career Development
Comparative Effectiveness Research (Kaplan)
D
The AHA and You
G
Aug 1
(Wed)
Biases/Confounding/Causality/Policy (Bertoni/Criqui/Labarthe/Angell) (break 10:00 – 10:30) 4 lectures, 35 minutes each
(Howard)
(Close at 12:00) E
Sample Size and Power
Study Design – 2 (Groups)
(1:00-2:00) (Greenland)
(Feldman) 2
(Thu)
Chronic Heart Failure (Peterson)
Study Design – 3 (Groups)
(on your own)
Reading/ Consultation
Reading/ Consultation
(Greenland) 3
(Fri)
CVH Policy: Federal, State, and Local (Labarthe)
Study Design – 4 (Groups)
F (11:30 –1:00)
A – Opening Banquet B – Program Orientation C – Special Dinner Arrangements D – Group Dinner
Presentation of Study Designs (1:00 – 3:30; break 3:30-4:00) (All) E – Optional Group Outing
D
(Anderson)
(All) F – Special Lunch Arrangements
Evaluation (4:30 – 5:00) (All)
G – Closing Banquet
Learning Objectives The learner should be able to plan research and practice and evaluate evidence by • applying rigorous definitions of cardiovascular disease (CVD) and cardiovascular health (CVH) and distinguishing the major forms of CVD • relating effort to the course of development of coronary heart disease (CHD) • applying rigorous definitions of an epidemic, interpreting the epidemic process and demonstrating the purpose of epidemiology dd t ti th f id i l • estimating the frequency of occurrence of CVD and ideal CVH in the US in the 20th & early 21st Centuries • assessing CVD as a global phenomenon • evaluating the epidemiologic transition as this concept applies to CVD & CVH • predicting plausible scenarios regarding the likely burden of CVD and bounty of CVH in the future • assessing and evaluating CVH as an alternative to CVD
Cardiovascular Disease as an Epidemic Process and Cardiovascular Health as an Alternative David Goff July 2012 No conflicts or unlabeled use to disclose.
July 2012
Epidemic Process
2
What is CVD?
July 2012
Epidemic Process
3
Percentage breakdown of deaths from cardiovascular diseases (United States: 2008) * - NotEpidemic a trueProcess underlying cause. July 2012 Source: NCHS.
What is CVD?
What is Coronary Heart Disease? • ICD 10 (Deaths)
• International Classification of Disease 10
– – – – –
– Diseases of the heart • I00‐I09, I11, I13, I20‐I51
– Cerebrovascular disease • I60‐I69
July 2012
Epidemic Process
4
5
July 2012
I20: Angina pectoris I21: Acute myocardial infarction I22: Subsequent myocardial infarction I24: Other acute ischemic heart diseases I25: Chronic ischemic heart disease
Epidemic Process
6
The Coronary Arteries
What is Coronary Heart Disease?
A Schematic View
• ICD/9 410–414 (Hospitalizations) – 410 — Acute Myocardial Infarction – 411 — Other Acute and Subacute Forms of Ischemic (Coronary) Heart Disease – 412 — Old Myocardial Infarction – 413 — Angina Pectoris – 414 — Other Forms of Chronic Ischemic Heart Disease
Source: Hutter, A. Scientific American Medicine. Dale, DC. Federman, DD. Eds., 5 Cardiovascular Medicine, Subsection IX 1996. July 2012
Epidemic Process
7
July 2012
Epidemic Process
8
What is Atherosclerosis?
July 2012
Epidemic Process
9
July 2012
Epidemic Process
10
Common Features of the Course of Coronary Heart Disease
What is an Epidemic?
Asymptomatic disease/ silent infarction Spontaneous resolution/ plaque enlargement
• The occurrence in a community or region of cases of an illness, specific health‐related behavior, or other health‐related events clearly in excess of normal expectancy clearly in excess of normal expectancy.
Recovery • without symptoms • stable angina • unstable angina Status of Disease
Advanced atherosclerotic lesions in the coronary arteries
Surface disruption or feature of a plaque/thrombosis
Symptomatic ischemia • unstable angina • myocardial infarction
• cardiac dysfunction
Short-term fatality (< 28 days) Sudden Death
– Last
Late recurrence (>28 days)
Late coronary death (>28 days)
Circumstances and Time Frame
Background conditions
Participating factors factors Participating (seconds to hours) (seconds to hours)
(years to decades)
July 2012
Epidemic Process
Acute event (seconds to hours)
Intermediate and late developments (days to years)
11
July 2012
Epidemic Process
12
Periodicity/Seasonality of Aseptic Meningitis
Views of an Epidemic Process • An epidemic considered broadly, from the perspectives of – variation in its manifestations • among different groups of persons • between places • over time – the conditions that favor its propagation – the possible interventions that could bring about its control
Gordis. Figure 2 – 16. Page 27. July 2012
Epidemic Process
13
July 2012
Epidemic Process
14
The Purpose of Epidemiology * Pop pulation
• To discover and understand epidemic processes and to apply this knowledge, through policy and practice, for control and prevention of disease prevention of disease.
* *
* * * ** * * * * * * * * * ** ** * * * * * ** * * * * * * * ** * * * ** * ** ** * * * * * * * * * **** * * ** ** * * * ** * * * * *
* *
*
*
* *
* * * *
* * *
Time July 2012
Epidemic Process
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July 2012
Epidemic Process
16
Prevalence of CVD in the US Pop pulation
• 82,600,000 Americans ages 20 years and older have CVD – High blood pressure — 76,400,000 – Coronary heart disease — 16,300,000 • Myocardial infarction — Myocardial infarction 7,900,000 7 900 000 • Angina pectoris — 9,000,000 – Stroke — 7,000,000 – Heart failure — 5,700,000 – Congenital cardiovascular defects — 650,000 ‐ 1,300,000
An Epidemic Curve
* *
* *
*
* * *
Time AHA Heart Disease and Stroke Statistics 2012 Update. Circulation. 2012;125:e12‐e230. July 2012
Epidemic Process
17
July 2012
Epidemic Process
18
Prevalence of CVD in adults ≥20 years of age by age and sex (NHANES: 2005–2008). 100 90
86.7 80.1
80 72.6
71.9
60
Per 1
Percent of Po opulation
70
50 39.3
40
37.2
10.1 10 0
4.2
45-54
30
8.9
55-64
65-74
75-84
85-94
Age 20 10
14.2 9.7
Men
Women
0 20-39
40-59
Men
60-79
80+
Incidence of CVD* by age and sex. (FHS, 19801980-2003). Source: NHLBI.
Women
Source: NCHS and NHLBI. These data include CHD, HF, stroke, and hypertension.
July 2012
19
Epidemic Process
©2010 American Heart Association, Inc. All rights reserved.
* Includes CHD, HF, stroke or intermittent claudication. Does not include July 2012 Epidemic Process 20 hypertension alone.
Roger VL et al. Published online in Circulation Dec. 15, 2010
CVD in the US
CVD Mortality by Place
• 1 in 3 adults have some form of CVD • CVD claims more lives than the next 3 leading causes of death combined. • About 33% of people killed by CVD are under age 75. • CVD mortality – 811,940 (32.8% of all deaths) underlying cause in 2008 – 1,354,527 (55%) underlying/contributing cause in 2008
AHA Heart Disease and Stroke Statistics 2012 Update. Circulation. 2012;125:e12-e230. July 2012
Epidemic Process
21
AHA Heart Disease and Stroke Statistics 2012 Update. Circulation. 2012;125:e12-e230. July 2012
Epidemic Process
July 2012
Epidemic Process
22
Deaths due to CVD* (United States: 1900–2008).
NHLBI Fact Book 2006 Source: NHLBI from NCHS reports. * - CVD does not include congenital.
July 2012
Epidemic Process
AHA Heart Disease and Stroke Statistics 2012 Update. Circulation. 2012;125:e12-e230.
23
24
NHLBI Fact Book 2006 July 2012
Epidemic Process
25
July 2012
Epidemic Process
Hospital discharges for cardiovascular diseases. United States: 1970‐2009.
26
CHD in the US • 405,309 deaths in 2008, ~ 1 / 1.3 minute • 1,255,000 AMI or fatal CHD (ages 35+) – 785,000 new attacks; 610,000 new MI – 470,000 recurrent; 325,000 recurrent MI – 34% case‐fatality • 195,000 silent MI each year • Lifetime risk of CHD after age 40 – 49% for men – 32% for women
Epidemic Process
AHA Heart Disease and Stroke Statistics 2012 Update. Circulation. 2012;125:e12-e230.
27
July 2012
Pe er 1,000 Persons
July 2012
Epidemic Process
AHA Heart Disease and Stroke Statistics 2012 Update. Circulation. 2012;125:e12-e230.
16 14 12 10 8 6 4 2 0 35-44
NHLBI Chart Book 2004 July 2012
Epidemic Process
29
45-54
55-64
White Men
Black Men
White Women
Black Women
65-74
Annual rate of first heart attack by age, sex and race. (ARIC Surveillance:1987--2004). Source: NHLBI. Surveillance:1987 July 2012
Epidemic Process
30
28
Hospital discharges for coronary heart disease by sex, United States: 1970–2009.
Stroke in the US • 133,990 deaths in 2007, ~1 q3‐4 minutes • 795,000 strokes each year – 610,000 new, 185,000 recurrent – 87% ischemic, 10% ICH, 3% SAH – 30 day fatality • ~8‐12% ischemic • ~37‐38% hemorrhagic
• 6‐month status – – – – – – July 2012
Epidemic Process
AHA Heart Disease and Stroke Statistics 2012 Update. Circulation. 2012;125:e12-e230.
31
50% some hemiparesis 35% with depressive symptoms 30% unable to walk without assistance 26% institutionalized 26% dependent in ADLs 19% aphasia
July 2012
Epidemic Process
AHA Heart Disease and Stroke Statistics 2012 Update. Circulation. 2012;125:e12-e230.
Prevalence of stroke by age and sex (NHANES: 2005–2008).
32
Age-adjusted death rates for stroke by sex and race/ethnicity, 2007.
18
80
16 14.5
70
14.8
67.1
14 12
Death Rate p per 100 000
Percent off Population
60
10 82 8.2
8
7.2
6 4
55.0
50
40
40.2
39.9 35.5
34.4 30.8
33.2
31.1 28.4
30
20 2.4 1.6
2 0.3
10
0.5
0 20-39
40-59
Men
Age
60-79
80+
0 White
Black
Hispanic
Asian/Pacific Islander
American Indian/Alaksa Native
Women Males
Source: NCHS and NHLBI.
Females
Source: NCHS and NHLBI.
July 2012
33
Epidemic Process
©2010 American Heart Association, Inc. All rights reserved.
Roger VL et al. Published online in Circulation Dec. 15, 2010
July 2012
34
Epidemic Process
©2010 American Heart Association, Inc. All rights reserved.
Roger VL et al. Published online in Circulation Dec. 15, 2010
CHF in the US P ercent of P op ulatio n
• Mortality – 56,830 deaths (underlying 2008) – 281,437 deaths (total mention 2008)
• 1,094,000 hospital discharges in 2009 – Up 174% from 1979 (400,000)
• Incidence 1% per year after age 65 • Lifetime risk 20% after age 40 – lifetime risk without antecedent MI is 1 in 9 for men and 1 in 6 for women.
14.7
4.9 0.3 0.2
1.9 1.4
40-59 Men
Epidemic Process
AHA Heart Disease and Stroke Statistics 2012 Update. Circulation. 2012;125:e12-e230.
35
12.8
9.1
20-39
• 1 year fatality 22% • 5 year fatality 42%
July 2012
16 14 12 10 8 6 4 2 0
60-79
80+
Women
Prevalence of heart failure by age and sex July 2012 Epidemic Process (NHANES: 2003 2003--2006). Source: NCHS and NHLBI.
36
45
700
41.9
Disc charges in Thousands
Per 1,000 Person Years
40 32.7
35 30 25
22.3
20 14.8
15 92 9.2
10
4.7
600 500 400 300 200 100
5 0
0
79
65-74
75-84
80
85
90
85+
Male
Men
95
00
06
Years
Age
Female
Women
Hospital discharges for heart failure by sex. (United States: 1979 1979--2006). Source: NHDS/NCHS and NHLBI.
Incidence of Heart Failure* by age and sex. (FHS: 1980 1980--2003). Source: NHLBI. Epidemic Process *July HF 2012 based on physician review of medical records and strict diagnostic criteria.
37
Note: Hospital discharges include people discharged alive, dead and status July 2012 Epidemic Process unknown.
38
Prrocedures in Thousands
1400 Obstetrical 72-75
1200
7.1
Cardiovascular 35-39
1000
6.5
Digestive System 42-54
800
5.6
Musculoskeletal 76-84
600
4.2
Female Genital Organs 65-71
400
Integumentary System 85-86
200
R Respiratory i t S System t 30 30-34 34
0
Nervous System 01-05
79
80
85
90
95
00
1.2 1.2
06 Urinary System 55-59
Years Catheterizations PCI Pacemakers
2 1.6
1
Hemic and Lymphatic 40-41
Bypass Carotid Endarterectomy
0.4
0
2
4
6
8
Millions
Trends in Cardiovascular Operations and Procedures (United States: 1979 1979--2006). Source: NCHS and NHLBI. July 2012
Note: InIn-hospital procedures only.
Epidemic Process
39
Number of Surgical Procedures in the 10 Leading Diagnostic Groups Source: July 2012(United States: 2006). Epidemic ProcessNHDS/NCHS and NHLBI.
200 Cardiovascular 390-459
324.1
Billio ons of Dollars
225.2
Digestive System 520-579 177.7
Mental 290-319
175.4
Nervous System 320-389 Injury and Poisoning 800-999
172.9 159.1
Respiratory System 460-519 126.1
Musculoskeletal system 710-739
102.7
Neoplasms 140-239
40
177.1
160 120 73.7
80
76.6 39.2
40
93.8
Genitourinary System 580-629
87.4
Endocrine System 240-279 0.0
50.0
100.0
0 150.0
200.0
250.0
Direct Costs of the 10 Leading Diagnostic Groups (Billions States:Process 2010). Source: NHLBI. July 2012 of dollars) (United Epidemic
300.0
350.0
41
Coronary Heart Disease
Stroke
Hypertensive Disease
Heart Failure
Estimated direct and indirect costs (in billions of dollars) of major cardiovascular diseases and stroke July 2012 Epidemic Process 42 (United States: 2010). Source: NHLBI.
Estimated Total Cost of CVD in 2010 • Total Costs:
CVD as a Global Phenomenon
$503.2 billion
AHA Heart Disease and Stroke Statistics 2010 Update. Circulation. 2010;121;e46‐e215. July 2012
Epidemic Process
43
July 2012
Epidemic Process
44
Projected age‐standardized death rates for 2005 from chronic diseases (per 100 000), for all ages and both sexes in 23 selected countries. Lancet 2007; 370: 1929–38.
July 2012
Epidemic Process
45
July 2012
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Secular Trends for Cardiovascular Disease and Other Cause-Specific Death Rates in the United States, 1900-1970.
Lancet 2008; 372: 1988–96. July 2012
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Projected global deaths (millions) for major chronic disease groups and other causes of death in 23 selected countries, 2005–15. Lancet 2007; 370: 1929–38.
The Epidemiologic Transition Phase of Transition
Deaths from Circulatory Disease (%)
Circulatory Problems
Risk Factors
Pestilence and famine
5 – 10
Rheumatic HD, infectious and deficiency cardiomyopathies
Uncontrolled infection, deficiency conditions
Receding pandemics
10 – 35
Above, plus hypertensive HD, hemorrhagic stroke
High salt diet, HTN, smoking
Degenerative and man-made diseases
35 – 55
All forms of stroke, ischemic heart disease
Atherosclerosis from fatty diets, sedentary lifestyle, smoking
Delayed degenerative diseases
Probably under 50
Stroke and IHD
Education and behavioral change leading to lower levels of risk factors
Source: From Disease Control Priorities in Developing Countries. Edited by DT Jamison et al., The International Bank for Reconstruction and Development/The World Bank. 1993.
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What is CVH?
Table 1. Changes in ranking for most important causes of death from 1990 to 2020 Disorder
Ranking 1990
Change in Ranking
2020 (baseline model)
Within Top 15 Ischaemic Heart Disease Cerebrovascular Disease Lower Respiratory Infections Diarrhoeal Diseases Perinatal Disorders Chronic Obstructive Pulmonary Disease Tuberculosis Measles Road traffic Accidents Road-traffic Trachea, bronchus, and Lung Cancers Malaria Self-inflicted Injuries Cirrhosis of the Liver Stomach Cancer Diabetes Mellitus
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
1 2 4 11 16 3 7 27 6 5 29 10 12 8 19
Outside Top 15 Violence War Injuries Liver Cancer HIV
16 20 21 30
14 15 13 9
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Epidemic Process
0 0 1 7 11 3 0 19 3 5 18 2 1 6 4
2 5 8 21
53
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Ideal CV Health Factors
Goal/Metric Current Smoking Adults ≥20 yo Children 12-19 yo
Circulation 2010; 121: 586-613 Presentation Title Here Really Long Title Here (on Master)
Epidemic Process
Never or quit >12 months ago Never tried; never smoked whole cigarette
Total Cholesterol Adults ≥20 yo Children 6-19 yo