1. Mississippi State Plan for Heart Disease and Stroke Prevention and Control J. Clay Hays, Jr., M.D.

2. Purpose of the Plan Provide framework to reduce morbidity and mortality associated with CVD Provide framework to reduce morbidity and mortality associated with CVD Provide education Provide education Create healthy environment Create healthy environment Provide quality health services Provide quality health services Focuses on disparities between groups Focuses on disparities between groups

3. We’re Number 1! We lead the nation in heart disease and stroke

4. Who developed the Plan?

5. Partnership Miss. State Dept of Health Miss. State Dept of Health Miss. Chronic Illness Coalition- CVD Advisory Committee Miss. Chronic Illness Coalition- CVD Advisory Committee Miss. Task Force on Heart Disease and Stroke Prevention Miss. Task Force on Heart Disease and Stroke Prevention

6. Who do we plan to target? Everyone Everyone Gender Gender Race Race Socioeconomic status Socioeconomic status Other cultural factors Other cultural factors

7. How do we expect to accomplish our Goals? Policy and environmental interventions focusing on populations instead of individuals Policy and environmental interventions focusing on populations instead of individuals Partnership development Partnership development Address specific community needs Address specific community needs

8. Develop a Database

9. Why did We decide to do this?

10. Mississippi Stats CVD is leading cause of death- 41% in 2001 CVD is leading cause of death- 41% in 2001 Our CVD mortality rate is the highest in the country Our CVD mortality rate is the highest in the country One in five occurs in people <65 old One in five occurs in people <65 old Prevalence- 4.3% heart disease and 2.4% stroke Prevalence- 4.3% heart disease and 2.4% stroke 160,000 Mississippians reported CVD 160,000 Mississippians reported CVD

11. More facts Mortality worse in men than in women Mortality worse in men than in women African americans> whites African americans> whites Claiborne county has the highest (675 per 100,000) Claiborne county has the highest (675 per 100,000) Three fourths of Miss. have one risk factor Three fourths of Miss. have one risk factor Cost 3.7 billion Cost 3.7 billion

12. Coronary Artery Disease (CAD): The Diagnosis Often Comes Too Late (Adapted from Levy et al.) Levy D et al in Textbook of Cardiovascular Medicine, 1998.

13. American Heart Association , 2000 Heart and Stroke Statistical Update, 1999; Braunwald E, N Engl J Med, 1997; Kannel WB in Atherosclerosis and Coronary Artery Disease, 1996. Vascular Disease: Scope of the Problem Vascular disease—and CAD in particular— is the leading cause of death in the US and other Western nations Vascular disease—and CAD in particular— is the leading cause of death in the US and other Western nations By 2020, cardiovascular disease will become the most common cause of death worldwide By 2020, cardiovascular disease will become the most common cause of death worldwide Due to the high initial mortality of vascular disease, the target of clinical practice must be aggressive risk factor management Due to the high initial mortality of vascular disease, the target of clinical practice must be aggressive risk factor management

14. Atherosclerosis: A Systemic Disease Aronow WS et al, Am J Cardiol, 1994. From a prospective analysis of 1886 patients aged  62 years, 810 patients were diagnosed with CAD as defined by a documented clinical history of MI, ECG evidence of Q-wave MI, or typical angina without previous MI. (Adapted from Aronow et al.)

15. Major Risk Factors for CAD Grundy SM et al, Circulation, 1998; Grundy SM, Circulation, 1999.

16. Most Myocardial Infarctions Are Caused by Low-Grade Stenoses Pooled data from 4 studies: Ambrose et al, 1988; Little et al, 1988; Nobuyoshi et al, 1991; and Giroud et al, 1992. (Adapted from Falk et al.) Falk E et al, Circulation, 1995.

19. (Adapted from Glagov et al.) Coronary Remodeling NormalvesselMinimalCAD Progression Compensatory expansion maintains constant lumen Expansion overcome: lumen narrows SevereCADModerateCAD Glagov et al, N Engl J Med, 1987.

20. Atheroma Morphology by Ultrasound “Soft” Lipid-Laden Plaque “Hard” Fibrous Plaque

24. Thin Cap With Lipid Core Thick Stable Fibrotic Cap Same Lumen Size: Different Atheromas

25. Atherosclerosis Begins in Childhood (Adapted from Berenson et al.) Berenson GS et al, N Engl J Med, 1998.

26. Tuzcu EM et al, in press. One in Six Teenagers Has Atheromas (Adapted from Tuzcu et al.)

27. CAD: Silent Disease Necessitates Aggressive Risk Factor Management IVUS corroborates necroscopy studies, proving that atherosclerosis begins in youth IVUS corroborates necroscopy studies, proving that atherosclerosis begins in youth CAD progresses silently; the initial presentation is usually MI or sudden death CAD progresses silently; the initial presentation is usually MI or sudden death Most atheromas are extraluminal, rendering them angiographically silent Most atheromas are extraluminal, rendering them angiographically silent The only reasonable approach is early and aggressive risk factor management The only reasonable approach is early and aggressive risk factor management Berenson GS et al, N Engl J Med, 1998; Tuzcu EM et al, in press; Levy D et al in Textbook of Cardiovascular Medicine, 1998 ; Yamashita T et al, Progress in Cardiovascular Diseases, 1999; Topol EJ et al, Circulation, 1995. Kannel WB in Atherosclerosis and Coronary Artery Disease, 1996.

28. The Correlation Between Atherosclerosis and Risk Factors Begins Early (Adapted from Berenson et al.) Berenson GS et al, N Engl J Med, 1998.

29. Small Increases in Cholesterol Lead to Dramatic Increases in CAD Death (Adapted from Neaton et al.) Neaton JD et al, Arch Intern Med, 1992.

30. CAD: Not Just a Lipid Disease Half of all MIs occur in normolipidemic patients Half of all MIs occur in normolipidemic patients Smoking Accounts for 200,000 cardiovascular deaths annually Smoking Accounts for 200,000 cardiovascular deaths annually Diabetes Affects 16 million Americans—and is growing Diabetes Affects 16 million Americans—and is growing Hypertension Confers as much risk for MI as smoking or dyslipidemia Hypertension Confers as much risk for MI as smoking or dyslipidemia Systolic hypertension is an even greater indicator of CAD risk than diastolic hypertension Systolic hypertension is an even greater indicator of CAD risk than diastolic hypertension Braunwald E, N Engl J Med, 1997; Grundy SM et al, Circulation, 1998; The Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure and the National High Blood Pressure Education Program Coordinating Committee, Arch Intern Med, 1997.

31. Systolic BP Confers Incremental Risk Even Within “Normal” Levels (Adapted from Neaton et al.) Neaton JD et al, Arch Intern Med, 1992.

32. Diabetes: Half of All Patients Are Unaware of Their Condition CAD is the leading cause of hospitalization and death among patients with type 2 diabetes (NIDDM) CAD is the leading cause of hospitalization and death among patients with type 2 diabetes (NIDDM) Patients with both type 1 and type 2 diabetes are at a high short-term risk of CAD-related end points Patients with both type 1 and type 2 diabetes are at a high short-term risk of CAD-related end points Insulin resistance increases risk and may exist for 25 years or more before diabetes is diagnosed Insulin resistance increases risk and may exist for 25 years or more before diabetes is diagnosed Patients with diabetes tend to cluster other risk factors (such as hypertension and dyslipidemia) while diabetes confers risk unto itself Patients with diabetes tend to cluster other risk factors (such as hypertension and dyslipidemia) while diabetes confers risk unto itself Aronson D et al in Atherosclerosis and Coronary Artery Disease, 1996; Grundy SM et al, J Am Coll Cardiol, 1999.

33. UK Prospective Diabetes Study Group, BMJ, 1998. *UK Prospective Diabetes Study Group. *UK Prospective Diabetes Study Group. UKPDS*: The Case for Aggressive Blood Pressure Control Mean final BP: More-aggressive control, 144/82 mm Hg Less-aggressive control, 154/87 mm Hg Mean final BP: More-aggressive control, 144/82 mm Hg Less-aggressive control, 154/87 mm Hg

34. How do we plan to address problems? Physical Activity Physical Activity Address Nutritional needs Address Nutritional needs Tobacco cessation Tobacco cessation Identify Sociocultural Factors (Jackson Heart Study) Identify Sociocultural Factors (Jackson Heart Study)

35. CAD Risk Factors: Minimal and Optimal Grundy SM, Circulation, 1999; American Heart Association Consensus Panel, Circulation, 1995; The Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure and the National High Blood Pressure Education Program Coordinating Committee, Arch Intern Med, 1997.

36. Multiple Risk Factors: Additive Risk Grundy SM et al, J Am Coll Cardiol, 1999; Data on file, Pfizer Inc., New York, NY. Risk of developing CAD over 10 years according to specified BP levels and other risk factors. Calculations are based on a Framingham Heart Study computer program, which includes variables for systolic BP, diastolic BP, TC, HDL-C, LVH by ECG, cigarette smoking, and glucose intolerance. The following remained constant unless otherwise indicated: male, age 45 years, TC 180 mg/dL, HDL 45, and nonsmoker. Elevated LDL-C estimated based on TC 250 mg/dL with triglycerides 200 mg/dL. (Data on file, Pfizer Inc.)

37. OBESITY

38. Where do we Start? Communities Communities Schools Schools Worksites Worksites Healthcare centers Healthcare centers

39. Conclusions: Risk Factor Management Atherosclerosis begins in childhood and is strongly associated with major CAD risk factors from the youngest ages Atherosclerosis begins in childhood and is strongly associated with major CAD risk factors from the youngest ages Hypertension (particularly systolic), diabetes, and smoking— in addition to dyslipidemia—confer comparable risks Hypertension (particularly systolic), diabetes, and smoking— in addition to dyslipidemia—confer comparable risks The effect of these risk factors is continuous, extending even into the “normal” range The effect of these risk factors is continuous, extending even into the “normal” range Therefore, aggressive risk factor modification is the most effective strategy for reducing the consequences of CAD Therefore, aggressive risk factor modification is the most effective strategy for reducing the consequences of CAD Atherosclerosis begins in childhood and is strongly associated with major CAD risk factors from the youngest ages Atherosclerosis begins in childhood and is strongly associated with major CAD risk factors from the youngest ages Hypertension (particularly systolic), diabetes, and smoking— in addition to dyslipidemia—confer comparable risks Hypertension (particularly systolic), diabetes, and smoking— in addition to dyslipidemia—confer comparable risks The effect of these risk factors is continuous, extending even into the “normal” range The effect of these risk factors is continuous, extending even into the “normal” range Therefore, aggressive risk factor modification is the most effective strategy for reducing the consequences of CAD Therefore, aggressive risk factor modification is the most effective strategy for reducing the consequences of CAD Berenson GS et al, N Engl J Med, 1998; Braunwald E, N Engl J Med, 1997; Neaton JD et al, Arch Intern Med, 1992; Kannel WB in Atherosclerosis and Coronary Artery Disease, 1996.

40. “ Awaiting overt signs and symptoms of coronary disease before treatment is no longer justified.” “In some respects, the occurrence of symptoms may be regarded more properly as a medical failure than as the initial indication for treatment.” —William B. Kannel, MD Department of Medicine Boston University Medical Center “ Awaiting overt signs and symptoms of coronary disease before treatment is no longer justified.” “In some respects, the occurrence of symptoms may be regarded more properly as a medical failure than as the initial indication for treatment.” —William B. Kannel, MD Department of Medicine Boston University Medical Center Kannel WB in Atherosclerosis and Coronary Artery Disease, 1996.

41. Carotid Disease: A Reliable Predictor of Coronary Risk Carotid atherosclerosis, even when very mild, is associated with MI and sudden cardiac death Carotid atherosclerosis, even when very mild, is associated with MI and sudden cardiac death Ultrasound-derived carotid intimal-medial thickness (IMT) has been shown to predict the risk of MI Ultrasound-derived carotid intimal-medial thickness (IMT) has been shown to predict the risk of MI The same risk factors predispose patients to atherosclerosis in both the coronary and carotid arterial systems The same risk factors predispose patients to atherosclerosis in both the coronary and carotid arterial systems Salonen R in Risk Factors for Ultrasonographically Assessed Common Carotid Atherosclerosis, 1991; O’Leary DH et al, N Engl J Med, 1999; Androulakis AE et al, Eur Heart J, 2000.