The Global Burden of Cardiovascular Health Banff 2012 CP1271671-5
Global Burden of Cardiovascular Disease – 2002 Total deaths – 57 million Cardiovascular HIV TB Malaria 16.7 million 5 million Developing (LIMC) countries • 80% of worldwide CV deaths • Occur at a younger age – impact on workforce and productivity • 2010 – 70% of the elderly will live in the developing world Lopez: Lancet, 2006; Reddy: NEJM, 2004 WHO Global Status Report, 2011 3125664-4
Changing Distribution of the Causes of Death in P Rep of China 100 Unknown Proportion of deaths (%) Injury Other non-communicable diseases 80 Chronic obstructive pulmonary disease Cerebro-cardiovascular disease 60 Cancer Maternal and perinatal conditions 40 Communicable diseases World Bank Report on China 20 August 2011 “Reduction in mortality from 0 CVD by only 1% between 2010- 2040 will save $10.7 trillion – 1973 2005 68% of China’s GDP in 2010 Year Lancet 2011 Yang: Lancet, 2008 3175698-3
Contrasting Burdens of Disease in India Prevalence of obesity in Population undernourished affluent school children in Delhi • Age 4-17 yr 1990-92 – 214.5 million • Overweight – 22% 1999-01 – 213.7 million • Obese – 6% FAO report Sharma: Public Health Nutrition, 2007 Changing demographics CV disease in India • Leading cause of death (approx • Aged <25 yr – 51% 1/3 of total deaths) • Aged 65 yr – 5% • Expected to double in 10 yr 6.2% (2020) • 2015 – 50% of world’s CAD 10.2% (2040) deaths < age 50 yr among 1.4 billion South Asians globally Enas: Indian Heart J, 2008 3060478-2
Stages of Epidemiologic Transition Proportion of Life death due Dominant form expectancy to CVD (%) of CVD death Description Stage 1 Pestilence and famine • Malnutrition 35 yr <10 Infectious (RHD) • Infectious diseases Nutritional Stage 2 Receding pandemics • Improved nutrition 50 yr 10-35 Infectious (RHD) and public health • Chronic disease Stroke – hemorrhagic • Hypertension Omran: Milbank Mem Fund Q, 1971 Olshansly: Millbank Mem Fund Q, 1986 Gaziano: Circ, 2003 Yusuf: Circ, 2005 3008698-4
Stages of Epidemiologic Transition Proportion of Life death due Dominant form Description expectancy to CVD (%) of CVD death Stage 3 Degenerative and man-made diseases • fat and caloric intake IHD* >60 yr 35-65 • Tobacco use Hemorrhagic Stroke • Chronic disease deaths > infections, malnutrition Ischemic Stage 4 Delayed degenerative diseases • Leading causes of 40-50 >70 yr • IHD** mortality CV and • Stroke cancer deaths Ischemic • Prevention and Tx delays onset • CHF • Age-adjusted CV death reduced * Greater in high socioeconomic groups Omran: Milbank Mem Fund Q, 1971 ** Younger pt – lower socioeconomic status Olshansly: Millbank Mem Fund Q, 1986 Elderly – higher socioeconomic status Gaziano: Circ, 2003 Yusuf: Circ, 2005 3008698-5
Socioeconomic Status and Incident CV Events CV Event-Free Survival Education Income 1.00 CVD event-free survival probability $100,000 • 22,688 MS $50,000- subjects 0.98 BS 99,999 Doctorate/ • Women’s MD $40,000- 49,999 2-4 years Health Study nursing 0.96 $30,000- • Apparently 39,999 <2 years nursing healthy female health 0.94 $20,000- 29,999 professionals $19,000 0.92 0 2 4 6 8 10 12 0 2 4 6 8 10 12 Follow-up (yr) Follow-up (yr) Alberts: Circ, 2006 CP1254525-2
Risk Factors Associated with MI in Africa INTERHEART Study Socioeconomic Status and OR for MI Income Years of Formal Education 2.0 3.0 1.8 Black Africans 2.5 1.6 (Phase 3) Black Africans Odds ratio Odds ratio (Phase 3) 1.4 2.0 Colored 1.2 Africans 1.0 1.5 Colored 0.8 Europeans/ Africans 1.0 other (Phase 4) 0.6 0.4 0.5 Europeans/ 0.2 other (Phase 4) 0.0 0.0 8 9-12 Post Low Intermediate High years years secondary income income income educ Population attributable risk for MI • Smoking history • Abdominal obesity 89.2% • Diabetes history • Apo B/Apo A-1 ratio • Hypertension history Steyn: Circ, 2005 3104026-03
Attained Education Level (AEL) and Impact on Risk Factors • REACH registry Associations with AEL • 61,332 subjects Risk factor HIC LIC • Established CVD or Obesity multiple risk factors * Smoking Education levels Hypertension • 0-8 yr Diabetes • 9-12 yr Hypercholesterolemia • Trade/technical Disease in • University/college 2 vascular beds Increased among women; Goyal: Circ, 2010 * 3069635-5
Spouse Behavior and CHD in Men Framingham Study 10-Year Incidence of CHD (Men Aged 45-64 Years) 30 24.0 25 23.1 20.0 20 14.9 % 15 11.5 11.1 10 5.3 5 0 n= 19 26 26 94 25 36 40 8 9 8 13 12 13 Wife's education 9-12 13 8 Husband's education 9-12 Years Haynes: Am J Epidem, July 1984
• The negative impact Phase 5 of social upheaval (phase of increasing CV and health regression mortality) • The age of inactivity ? and obesity 3069635-2
Declining Life Expectancy in Russia Life Expectancy at Birth 80 U. S. females Russian females Life expectancy (yr) 75 70 U. S. males 65 60 Russian males Heart disease and Economic and stroke – 65% of Anti-alcohol social instability 55 decline in life campaign • alcohol expectancy • tobacco Perestroika 0 1962 1965 1970 1975 1980 1985 1990 1994 Years Notzon: JAMA, 1998 CP1284274-2
Phase 5 – the Age of Inactivity and Obesity Mortality Rates from CHD – USA ? Estimated Annual Percentage Change (EAPC) Males -8 Age 35-44 years -6.2 Age 55 years -6 EAPC -3.7* -4 (%) -2.6 -2.3* -2 -0.5 -1.9* *P<0.05 vs prior period 0 1980-89 1989-2000 2000-2002 Time period Females -8 -5.4 -6 -4.8* -4 EAPC -1.5 (%) -1.2* -2 0 1.5 *P<0.05 vs prior period 2 1980-89 1989-2000 2000-2002 Time period Ford and Copewell: JACC, 2007 3062626-1
Risk Factors for CVD in the Developing World : Traditional and Novel ? CP1271671-5
Risk of AMI After Adjustment for Age, Sex, and Geographic Region Risk factor Sex • Current F smoking M • Diabetes F M • HTN F M All 9 risk factors • Abdomial F account for obesity M 90.4% of • ApoB/ApoA1 F ratio M population • Psycho- F attributable risk social index M (PAR) • Fruits/veg F M • Exercise F M • Alcohol F M Female 0.25 0.5 1 2 4 8 16 Male Odds ratio (99% CI) Yusuf: Lancet, 2004 CP1274880-8
The Potential Epidemic of CVD in Developing Countries • Diet/lack of exercise • Tobacco incl second-hand smoke • Aging society Hostile CV • HIV survivors environment • Air pollution • Rural urban migration Psychosocial/economic stressors • Culture Obesity Traditional healers Genetic/phenotypic vulnerability? – thrifty Pre- gene concept? disposing factors • Salt sensitivity • Insulin resistance “The perfect storm” • Limited national • Lipid/fat resources metabolism • Lack of infrastructure • Low birth weights 3125664-5
“The human race has had long experience and a fine tradition in surviving adversity; but we now face a task for which we have little experience, the task of surviving prosperity” Alan Gregg 1890-1957 Rockefeller Foundation CP1344939-4
CAD in the UK and USA – 1920’s Angina pectoris “It is a rare disease…a case a year is about average, even in the large metropolitan hospitals.” Osler: Principles and Practice of Medicine, 1912 “Seven -fold increase Recent MI (UK prior to WWI) 1-2 from 1907-44 to necrosies/year with recent coronary 1944-49 in the thrombosis/AMI The London Hospital number of cases of coronary heart Morris: Lancet, 1951 disease.” CHD (USA) “The disease in my youth was hardly a problem…but I know that my professors did have occasional cases among their well-to-do patients whom they cared for at home White PD: Am J Pub Health, 1957 3100028-7
Spectrum of Heart Disease in Urban Blacks in S Africa – 2006 The Heart of Soweto Study 1,593 New Cases of • 1.1 million est. Cardiovascular Disease • 85% black Other diagnoses Hypertension 9% 59% women 19% CAD 10% Mean age 52-8 yr (6% – blacks 38% – other) CV risk factors – 87% Valvular heart disease (17%) Heart failure (58% – rheumatic) 44% Sliwa: Lancet, 2008 CP1305101-2
Proportion of Reduction in Deaths Due to CHD Attributable to Treatments and Changes in Risk Factors Treatments Risk factors Unexplained New Zealand, 1974-81 IMPACT New Zealand, 1982-93 Holland, 1978-85 IMPACT Scotland, 1975-94 IMPACT England and Wales, 1981-2000 IMPACT Sweden, 1986-2002 Finland, 1972-92 IMPACT Finland, 1982-97 IMPACT Iceland, 1981-2006 U.S., 1968-76 U.S., 1980-90 IMPACT U.S., 1980-2000 IMPACT Poland, 1991-2005 0 20 40 60 80 100 % Bandosz: BMJ, 2012 3172921-1
“Nobody in football should be called a genius. A genius is a guy like Norman Einstein.” Joe Theisman CP1234288-1
The Positive Model of the Hunter-Gatherer Life Style • 10 Aborigines • Derby, W. Australia • Diabetics Baseline 7 weeks as hunter-gatherers O’Dea: Diabetes 1984 Brown: 2011 3147010-13
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