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Cardiovascular Disease Matthew L. Boulton, MD, MPH October 14, 2014 PUBHLTH 350

Outline What is cardiovascular disease? Risk factors Aging population “Global tsunami” of cardiovascular disease Screening Discussion question

Jacobsen chapter 7. Noncommunicable diseases and aging.

Cardiovascular Disease (CVD) Atherosclerosis: walls of arteries that carry oxygen-rich blood from heart to the body thicken and harden compromising blood flow and oxygenation When atherosclerosis occurs, coronary heart disease may result which causes reduced blood flow to the heart (ischemia) often presenting as angina Jacobsen chapter 7. Noncommunicable diseases and aging.

Cardiovascular Mortality More than one-third of older men and women die of cardiovascular disease –Heart attacks (myocardial infarctions): ischemia causes part of the heart muscle to die –Stroke (cerebrovascular accidents): ischemia in the brain resulting from a blocked blood vessel or cerebral hemorrhage Jacobsen chapter 7. Noncommunicable diseases and aging.

Modifiable Risk Factors Tobacco use Physical inactivity Obesity Unhealthy diet Excessive alcohol consumption Unmanaged diabetes Poor lipid profile (elevated cholesterol) Hypertension Jacobsen chapter 7. Noncommunicable diseases and aging.

Hypertension Untreated hypertension (BP > 140/90 mm Hg) is major contributor to risk of stroke and increases likelihood of heart failure Increasingly recommend treating persons with borderline hypertensive disease (isolated systolic or diastolic hypertension) Jacobsen chapter 7. Noncommunicable diseases and aging.

Other Risk Factors Lower SES associated with increased risk –People with lower SES have fewer resources for addressing modifiable risk factors High temperatures and poor air quality increase the incidence of heart attacks and strokes Most significant predictor of cardiovascular disease is aging

Global Aging Ages : 700 million 2050: 2 billion About two-thirds of older adults live in low- income countries, and that proportion is rapidly increasing Ages : 100 million 2050: 400 million Jacobsen chapter 7. Noncommunicable diseases and aging.

“Global tsunami” of Cardiovascular Disease Over past 30 years, cardiovascular disease incidence has increased in low and middle- income countries and declined in many high- income countries Analysis of low and middle-income countries illustrates the limited capacity of these countries to effectively deal with the existing and projected dual burden of non-communicable diseases and communicable diseases Anand SS, Yusuf S. Stemming the global tsunami of cardiovascular disease. Lancet. 2011;377:

Change over time in mean BMI, BP, and total cholesterol by income category Anand SS, Yusuf S. Stemming the global tsunami of cardiovascular disease. Lancet. 2011;377:

Global BMI, BP & Cholesterol BMI is increasing across all income levels In high-income countries, blood pressure and total cholesterol are decreasing In middle-income countries, no major change in blood pressure and total cholesterol is decreasing In low-income countries, blood pressure is increasing and total cholesterol is decreasing Anand SS, Yusuf S. Stemming the global tsunami of cardiovascular disease. Lancet. 2011;377:

Solutions For most low and middle-income countries, joint programs for controlling both common communicable and non-communicable diseases are necessary Need to develop integrated teams and systems which have the capacity to tackle the common health problems of each country no matter the relative burden of communicable vs. non- communicable diseases Anand SS, Yusuf S. Stemming the global tsunami of cardiovascular disease. Lancet. 2011;377:

Integrated Approach Requires expanding the paradigm of health care beyond traditional physicians and nurses –Involvement of grassroots organizations, communities, school teachers, and trained health- care workers –Support of political leadership that understand the control of all diseases is linked to the prosperity of all nations of the world “Mass diseases and mass exposures require mass remedies.” - - Geoffrey Rose

Screening & Early Detection Screening: a preventive measure that encourages everyone in a well-defined population group to be tested for a disease based on evidence that members of the population are at risk and early intervention improves health outcomes Jacobsen chapter 7. Noncommunicable diseases and aging.

Questions to ask before starting a screening program Is the disease life threatening? Is the disease common in the target population? Is there an early asymptomatic stage of the disease that could be detected through screening? Is the test for early disease valid? (Does it have high sensitivity and high specificity?) Is the test acceptable to the target population? Is there an acceptable treatment for individuals found to have the disease? Are facilities for further testing and for treatment available to the target population? Jacobsen chapter 7. Noncommunicable diseases and aging.

Questions to ask for a cardiovascular screening program Important to detect risk factors at early stages –High blood pressure –High total cholesterol –High blood glucose –BMI

Are community health fairs, where screening for cardiovascular and other diseases regularly takes place, mostly a good or a bad idea from a public health perspective?