Transcript UC Irvine Preventive Cardiology - Heart Disease Prevention Program

New Concepts and
Strategies for Prevention of
Cardiovascular Disease
Nathan D. Wong, PhD, FACC, FAHA
Professor and Director, Heart Disease Prevention Program
Division of Cardiology, University of California, Irvine
Immediate Past President, American Society for
Preventive Cardiology
CVD and other major causes of death for all males and females
(United States: 2007).
450,000
421,918
400,000
391,886
350,000
292,857
300,000
Deaths
270,018
250,000
200,000
150,000
79,827
66,689
100,000
61,235
52,832
43,879
35,478
50,000
35,904
21,800
0
A
B
C
D
E
Males
F
A
B
D
F
C
E
Females
Source: NCHS and NHLBI. A indicates CVD plus congenital CVD; B, cancer; C, accidents; D, CLRD; E, diabetes; and F, Alzheimer's disease.
©2010 American Heart Association, Inc. All rights reserved.
Roger VL et al. Published online in Circulation Dec. 15, 2010
Deaths in Thousands
550
500
450
400
350
79
80
85
90
95
Years
Males
Females
00
06
Coronary Heart
Disease
14
Stroke
4
HF
6
52
7
17
High Blood Pressure
Diseases of the
Arteries
Other
Percentage breakdown of deaths from cardiovascular diseases
(United States:2004)
Source: NCHS and NHLBI.
Women and Heart Disease
• 1 in 3 women die of heart disease, but
only 4% fear of dying from heart
disease
• 1 in 27 women die of breast cancer, but
40% fear of dying of breast cancer
• Only 38% of women reported that their
doctors had ever discussed heart
disease with them.
www.goredforwomen.org/
Development of Atherosclerotic
Plaques
Fatty streak
Normal
Lipid-rich plaque
Foam cells
Fibrous cap
Thrombus
Ross R. Nature. 1993;362:801-809.
Lipid core
PDAY: Percentage of Right Coronary Artery Intimal
Surface Affected With Early Atherosclerosis
30
Intimal
surface
(%)
Men
Raised lesions 30
Fatty streaks
20
20
10
10
0
30
0
15-19 20-24 25-29 30-34
White
30
20
20
10
10
0
0
15-19 20-24 25-29 30-34
Black
Age (y)
PDAY= Pathobiological Determinants of Atherosclerosis in Youth.
Strong JP, et al. JAMA. 1999;281:727-735.
Women
15-19 20-24 25-29 30-34
White
15-1920-2425-2930-34
Black
Coronary Calcium Screening: Early
Detection of Heart Disease
CT Angiographic Image of the Heart
and Coronary Arteries
ACS
Positive remodeling (+), Soft plaque (+),
Fibrous plaque (+),
Calcification (-)
LAD
Motoyama et al. JACC 2007;50:319-26
Prevalence of Multi-Site Atherosclerosis
by Gender and Age: MESA Study
(CAC, AAC, ABI, and/or CIMT)
Men
Women
Wong ND et al. Atherosclerosis 2011
Major Risk Factors
Age (men 45 years; women 55 years)
Cigarette smoking (and passive smoking)
Elevated total or LDL-cholesterol
Hypertension (BP 140/90 mmHg or on
antihypertensive medication)
• Low HDL cholesterol (<40 mg/dL)†
• Family history of premature CHD
– CHD in male first degree relative <55 years
– CHD in female first degree relative <65 years
•
•
•
•
†
HDL cholesterol 60 mg/dL counts as a “negative” risk factor; its
presence removes one risk factor from the total count.
Other Recognized Risk Factors
• Obesity: Body Mass Index (BMI)
– Weight (kg)/height (m2)
– Weight (lb)/height (in2) x 703
• Obesity BMI >30 kg/m2 with overweight defined as
25-<30 kg/m 2
• Abdominal obesity involves waist circumference >40
in. in men, >35 in. in women
• Physical inactivity: most experts recommend at least
30 minutes moderate activity at least 4-5 days/week
• Psychosocial factors: depression, hostility, social
isolation, job strain
Six of the top 10 causes of death are lifestyle-related
risk factors for cardiovascular disease!
Obesity Trends* Among U.S. Adults:
BRFSS - 1985
No Data
<10%
JAMA 1999;282:16, JAMA 2001;286:10.
10%-14%
15%-19%
20%-24%
25%-29%
>30%
Obesity Trends* Among U.S. Adults:
BRFSS - 1991
No Data
<10%
JAMA 1999;282:16, JAMA 2001;286:10.
10%-14%
15%-19%
20%-24%
25%-29%
>30%
Obesity Trends* Among U.S. Adults:
BRFSS - 1997
No Data
<10%
JAMA 1999;282:16, JAMA 2001;286:10.
10%-14%
15%-19%
20%-24%
25%-29%
>30%
Obesity Trends* Among U.S. Adults:
BRFSS - 2001
No Data
<10%
JAMA 1999;282:16, JAMA 2001;286:10.
10%-14%
15%-19%
20%-24%
25%-29%
>30%
Obesity Trends* Among U.S. Adults:
BRFSS - 2008
No Data
<10%
10%-14%
15%-19%
20%-24%
25%-29%
>30%
By 2020, close to 40% of the US adult population is expected to
be obese!
Percent of Population
20
18
16
14
12
10
8
6
4
2
0
18.7
16.3
11.6
11
6.6
6.4
4.3
3.6
6-11
1971-74
12-19
1976-80
1988-94
2001-2004
Trends in prevalence of overweight among U.S. children and
adolescents by age and survey
(NHANES, 1971-74, 1976-80, 1988-94 and 2001-2004).
Source: Health, United States, 2006, unpublished data. NCHS.
Intra-abdominal (Visceral) Fat
The dangerous inner fat!
Front
Visceral AT
Subcutaneous AT
Back
The Metabolic Syndrome
Complex
Dyslipidemia
Endothelial
Dysfunction
Systemic
Inflammation
TG, LDL
HDL
Disordered
Fibrinolysis
Insulin
Resistance
Hypertension
Type 2 Diabetes
Adapted from the ADA. Diabetes Care. 1998;21:310-314;
Pradhan AD et al. JAMA. 2001;286:327-334.
Atherosclerosis
Visceral
Obesity
ATP III: The Metabolic Syndrome*
Risk Factor
Abdominal obesity†
(Waist circumference‡)
Men
Women
TG
HDL-C
Men
Women
Blood pressure
Fasting glucose
Defining Level
>102 cm (>40 in)
>88 cm (>35 in)
150 mg/dL
<40 mg/dL
<50 mg/dL
130/85 mm Hg or on meds
**110 mg/dL
*Diagnosis is established when 3 of these risk factors are present.
†Abdominal obesity is more highly correlated with metabolic risk factors than is
‡Some men develop metabolic risk factors when circumference is only
BMI.
marginally ; ** new ADA guideline for impaired fasting glucose >=100 mg/dl
increased.
Expert
Panel on Detection, Evaluation, and Treatment of
High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.
© 2001, Professional Postgraduate Services®
www.lipidhealth.org
Diagnostic Criteria for
Glycemic Abnormalities
FPG
Hemoglobin A1C
2-Hour PG on OGTT
Diabetes Mellitus
Diabetes Mellitus
Diabetes Mellitus
126 mg/dL
7.0 mmol/L
6.5%
Prediabetes
100 mg/dL
Prediabetes
5.6 mmol/L
Normal
200 mg/dL
6.0%
140 mg/dL
Impaired Glucose
Tolerance
Normal
11.1 mmol/L
7.8 mmol/L
Normal
To convert mg/dL to mmol/L multiply mg/dl by 0.055
FPG=Fasting plasma glucose, PG=Plasma glucose, OGTT=Oral glucose tolerance test
The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care 2001;24:S5-S20
American Diabetes Association. Diabetes Care 2010;33:S11-61
Cardiovascular Disease (CVD) and Total Mortality:
US Men and Women Ages 30-74
(age, gender, and risk-factor adjusted Cox regression) NHANES II Follow-Up
(n=6255)(Malik and Wong, et al., Circulation Sept 8, 2004)
6
****
5
4
****
3
2
****
****
**
**** ****
*
1
0
CVD Mortality
Total Mortality
* p<.05, ** p<.01, **** p<.0001 compared to none
None
MetS
Diabetes
CVD
CVD+Diabetes
Causes of Mortality in Patients
With Diabetes
Diabetes is considered a “risk equivalent” for coronary heart disease
Annual CHD Event Rates (in %) by Calcium Score Events by CAC
Categories in Subjects with DM, MetS, or Neither Disease
(Malik and Wong et al., Diabetes Care 2011)
Coronary Heart Disease
4
Annual
CHD
Event
Rate
4
3.5
3
2.5
2
1.5
1
0.5
0
3.5
1.9
1.5
0.4
0.8
0.2
0.1
0
2.1
0.4
1-99
2.2
1.3
DM
MetS
Neither MetS/DM
100-399
400+
Coronary Artery Calcium Score
ACCF/AHA 2010 Guideline: CAC Scoring for CV risk assessment in
asymptomatic adults aged 40 and over with diabetes (Class IIa-B)
Total Cholesterol Distribution:
CHD vs Non-CHD Population
Framingham Heart Study—26-Year Follow-up
No CHD
35% of CHD
Occurs in
People with
TC<200 mg/dL
150
CHD
200
250
300
Total Cholesterol (mg/dL)
Castelli WP. Atherosclerosis. 1996;124(suppl):S1-S9.
1996 Reprinted with permission from Elsevier Science.
14-y incidence
rates (%) for CHD
Low HDL-C Levels Increase CHD Risk Even
When Total-C Is Normal (Framingham)
14
12
10
8
6
4
2
0
< 40 40–49 50–59  60
HDL-C (mg/dL)
 260
230–259
200–229
< 200
HDL-C Recommendations: >50 mg/dl women, >40 mg/dl men,
optimal HDL-C >60 mg/dl.
Castelli WP et al. JAMA 1986;256:2835–2838
Primary and Secondary
Prevention Trials With Statins
1° prevention statin
2° prevention statin
1° prevention placebo
2° prevention placebo
30
4S
Event Rate (%)
25
4S
20
15
HPS
10
CARE
LIPID
LIPID
HPS
CARE
AFCAPS
5
WOSCOPS
AFCAPS
0
80
90
WOSCOPS
100 110 120 130 140 150 160 170 180 190 200
LDL-C Achieved (mg/dL)
Adapted from Ballantyne CM. Am J Cardiol. 1998;82:3Q-12Q.
NCEP ATP III: LDL-C Goals
LDL-cholesterol level
CHD or CHD risk
equivalents
≥2 risk
factors
190
Target
160
mg/dL
160
130
100
<2 risk
factors
Target
130
mg/dL
Target
100
mg/dL
100 mg/dL = 2.6 mmol/L; 130 mg/dL = 3.4 mmol/L; 160 mg/dL = 4.1 mmol/L
National Cholesterol Education Program, Adult Treatment Panel III,
2001. JAMA 2001:285;2486–2497
Lipid Management Goal: Persons
with Pre-existing CHD
I IIa IIb III
LDL-C should be less than 100 mg/dL
I IIa IIb III
Further reduction to LDL-C to < 70 mg/dL is
reasonable
If TG >200 mg/dL, non-HDL-C should be < 130 mg/dL*
*Non-HDL-C = total cholesterol minus HDL-C
P. Ridker
hs-CRP Adds to Predictive Value of TC:HDL
Ratio in Determining Risk of First MI
Relative Risk
5.0
4.0
3.0
2.0
1.0
0.0
High
Medium
High
Medium
Low
Total Cholesterol:HDL Ratio
Ridker et al, Circulation. 1998;97:2007–2011.
Low
4-Year Progression To Hypertension:
The Framingham Heart Study
Participants age 36 and older
50
37
Patients (%)
40
30
18
20
10
5
0
Optimal
Normal
(<120/80 mm
(130/85 mm
Hg)
Hg)
Vasan, et al. Lancet 2001;358:1682-86
High-Normal
(130-139/85-89 mm
Hg)
Distribution of Hypertension Subtype in the untreated
Hypertensive Population in NHANES III by Age
ISH (SBP 140 mm Hg and DBP <90 mm Hg)
SDH (SBP 140 mm Hg and DBP 90 mm Hg)
IDH (SBP <140 mm Hg and DBP 90 mm Hg)
100
17%
16%
<40
40-49
16%
20%
20%
11%
50-59 60-69
Age (y)
70-79
80+
80
Frequency of
hypertension 60
subtypes in all
untreated
40
hypertensives
(%)
20
0
Numbers at top of bars represent the overall percentage distribution of untreated hypertension by
age.
Franklin et al. Hypertension 2001;37: 869-874.
Diabetes Prevention Program:
Reduction in Diabetes Incidence
The 2010 Dietary Guidelines
23 Recommendations Jan 31, 2011
•
•
•
•
•
Enjoy your food, but eat less.
Avoid oversized portions.
Make half your plate fruits & vegetables.
Switch to fat free or low fat milk (1%).
Compare sodium in foods e.g. soup, bread &
frozen meals & choose foods with lower numbers.
• Drink water instead of sweetened beverages.
www.dietaryguidelines.gov
Eight Diet/lifestyle Recommendations
Amer Heart Assoc: 2006
1. Balance kcal intake & physical activity to achieve
optimal body weight.
2. Consume a high fiber diet rich in fruits &
vegetables, legumes & whole grains.
3. Consume fish, especially oily fish at least 2x /wk.
AHA 2006
Eight Diet & Lifestyle Recommendations
4. Limit saturated fat <7%, trans fat <1%,
cholesterol intake<300 mg/d.
– Choose lean meat, poultry, fish & vegetarian
alternatives
– Select fat free, 1% fat or low fat dairy products
– Minimize intake of partially hydrogenated fats
AHA 2006
Eight Diet & Lifestyle Recommendations
5. Minimize sugar in food & beverages
6. Choose foods with little or no salt
(2011 recommendation: sodium intake <1500
mg/day)
7. If you consume alcohol, use moderation
8. When eating out, use AHA recommendations
Reading
Food Labels
Be wary of “healthier foods”
that advertise containing whole grains
but that may also significant amounts
of sugar and trans fat
(e.g., partially
hydrogenated oils)
Always check dietary fiber, fat,
and sugar content per serving
Choose whole or multigrain
bread, check dietary fiber content
Encourage Increased Physical Activity
• Brisk walking is an ideal physical activity for those
without orthopedic issues
• Walking uses the patient’s increased body weight
to increase energy expenditure
• Pedometers provide daily feedback - 10,000 Steps
Per Day
Mylifecheck.heart.org
Age-standardized prevalence estimates for poor, intermediate and
ideal cardiovascular health for each of the seven metrics of
cardiovascular health in the AHA 2020 goals, among US adults >20
years of age, NHANES 2005-2006 (baseline available data as of
January 1, 2010).
100.0
22.9
33.2
80.0
45.2
46.6
41.7
Percentage
61.4
60.0
72.2
32.9
23.2
40.0
76.8
38.4
41.2
3.2
20.0
30.4
33.8
24.5
31.7
15.0
17.1
Total
Cholesterol
Blood
Pressure
8.2
0.0
Current
Smoking
Body Mass
Index
Physical
Activity
Poor
Healthy Diet
Score
Intermediate
Fasting
Plasma
Glucose
Ideal
Fewer than 1% of US adults are at ideal levels for
all 7 measures of cardiovascular health!
©2010 American Heart Association, Inc. All rights reserved.
Roger VL et al. Published online in Circulation Dec. 15, 2010
UCI Preventive Cardiology
Program
•
•
•
•
•
•
OC’s only multidisciplinary cardiovascular
prevention program
Patients meet regularly with cardiologist, dietitian,
and exercise physiologist
Focus on cardiac risk factor reduction and weight
loss through lifestyle modification
For persons with and without prior heart disease
who have one or more risk factors
Specialized biomarker and imaging tests (e.g.,
calcium scan) are available
Call 714-456-6699
Thank You!
For more information:
www.heart.uci.edu or www.heart.org
Email:
Nathan D. Wong, PhD
at: [email protected]