1. 8/7/20151 Prevention of Cardiovascular Diseases: Begin in Childhood! Ruth Collins-Nakai MD, MBA, FRCPC, FACC President InterAmerican Society of Cardiology

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3. 3 Outline  World status of CVDs  Argentinean status of CVDs  Prevention efficacy  Recommendations re risk factors  Role of CV specialist in prevention

4. 8/7/2015 1999 WHF "Impending Global Pandemic of CVDs 4 World Status of CVD  Represents 30% of all deaths worldwide (15 million deaths/year)  Leading cause of death and disability  CVD burden  in developing countries  Risk factors  worldwide

5. 8/7/20155 % GDP spent on health

6. 8/7/2015http://cvdinfobase.ic.gc.ca6 Population per Physician

7. 8/7/2015http://cvdinfobase.ic.gc.ca7

8. 8/7/2015http://cvdinfobase.ic.gc.ca8 Argentina CVD mortality: females

9. 8/7/20159 Argentina CVD mortality: females

10. 8/7/2015http://cvdinfobase.ig.gc.ca10 Argentina IHD mortality: males

11. 8/7/2015http://cvdinfobase.ic.gc.ca11 Argentina Diabetes: females males

12. 8/7/201512 Atherosclerosis: A Systemic Disease

13. 8/7/201513 Prevention Facts  Defined Risk Factors in adults associated with accelerated atherosclerosis and CVD rates*  Atherosclerosis begins in childhood * *  Extent of atherosclerosis in children correlated with same risk factors as in adults * * * *Strong JP et al JAMA 1999;281:727-735 * Berenson GS et al NEJM 1998;338:1650-1656 * * *Williams CL et al Circ. 2002;106:143-160

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15. 8/7/201515 0 20 40 60 80 % Age (Years) Aorta Coronary Arteries 2-1516-2021-2526-39 2-1516-2021-2526-39 p = 0.001 for trend toward increasing prevalence with age in aorta and coronary arteries. Early Appearance of Atherosclerosis: Bogalusa Heart Study Prevalence of Fibrous Plaque Lesions 0 20 40 60 80

16. 8/7/201516 The Evidence   physical activity associated with  life expectancy  Direct association between obesity & insulin resistance in children  Direct association between obesity & lipid levels in children  Tracking: BMI>weight>skinfold thicknesses>lipids>BP  Clusters of multiple risk factors persist strongly from child-to-adulthood

17. 8/7/201517 Risk Factors for Atherosclerosis Smoking Obesity High blood pressure Physical Inactivity High blood fat levels Diabetes Positive family history Other (ethnicity, anger)

18. 8/7/201518 10-Year % Probability of Event SBP 150-160++++++ Cholesterol 6.2-6.8 -+++++ HDL-C 0.8-0.9 --++++ Diabetes---+++ Cigarettes----++ ECG-LVH-----+ 4 6 10 14 21 40 Effect of Multiple Risk Factors on Probability of CAD: Framingham Study

19. 8/7/201519 Recommendations  Cardiovascular Health in Childhood (AHA Scientific Statement)  Circ 2002;106:143-160  Circ 2002;107:1562-1566  Canadian Cardiovascular Society Consensus Conference on Prevention of CVD: The Role of the CV Specialist  CJC 1999;15(supple.G)

20. 8/7/201520 Smoking

21. 8/7/201521 Tobacco  Complete cessation for those who smoke  No exposure to environmental tobacco smoke  No new initiation of cigarette smoking or tobacco use

22. 8/7/201522 Obesity  Appropriate body weight (BMI for age) (www.cdc.gov/growthcharts./)www.cdc.gov/growthcharts  Overall healthy eating pattern (limit salt, fat, calories & sugar > 2 years age)  Balance “Energy in = energy out” for weight  Begin treatment before adolescence

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24. 8/7/201524 20 15 10 5 0 6-11 yrs12-19 yrs 1963-701971-741976-801988-941999 Trends in prevalence of overweight in USA (CDC – NHANES) %

25. 8/7/201525 Physical Activity  Physical activity every day (60 minutes per day for children)  Reduce/limit sedentary time (e.g.. TV maximum 2 hours per day)  May add resistance training to aerobic activity in adolescents

26. 8/7/201526 Lipids & Lipoproteins  Total cholesterol 170mg/dL borderline; >200 mg/dL is  )  LDL-C <2.85 mmol/L recommended (USA<110mg/dL)  Triglycerides <1.5 mmol/L recommended (USA <150 mg/dL)  HDL-C >35 mg/dL recommended

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29. 8/7/201529 CAD Death Rate per 10,000 Person-years 100+90-9980-89 75-7970-74<70 <120 120-139 140-159 160+ Diastolic BP (mmHg) Systolic BP (mmHg) 20.6 10.3 11.8 8.8 8.5 9.2 11.8 12.6 12.8 13.9 24.6 25.3 25.2 24.9 16.9 23.8 31.0 25.8 34.7 43.8 38.1 80.6 37.4 48.3 Effect of SBP and DBP on Age-Adjusted CAD Mortality: MRFIT

30. 8/7/201530 Blood Pressure  Systolic & diastolic BP>90 th % for age, sex and height is abnormal (www.nhlbi.nih.gov/health/prof/heart/ hbp/hbp_ped.htm.) (www.nhlbi.nih.gov/health/prof/heart/ hbp/hbp_ped.htm.)  >130/~80 is almost always pathological in youth.  Use proven effective therapies recommended for adults (CPGs)

31. 8/7/201531 Diabetes  Adequate nutrition (neither over nor undernutrition) of pregnant women: Barker hypothesis  Limit sugar intake  Maintain normal weight for age & height  For type 1 diabetics, ongoing strict control (Hgb A1c)

32. 8/7/201532  Ethnicity (esp. South Asian / aboriginal/black/Hispanic)  Low socioeconomic level  Social isolation  Depression  Pregnancy (HTN and gestnl diabetes)  “Emerging” risk factors Other Risk Factors

33. 8/7/201533 Childhood Abuse Adverse childhood experiences (ACEs)  1.7x  risk with emotional abuse  1.7x  risk with crime in household  1.3x  risk with emotional neglect  1.3x  risk with substance abuse  Depressed affect OR 2.1  Anger: OR 2.5  7 or > ACEs  risk almost 4x Dong M et al CIRC 110; 2004

34. 8/7/201534 - - Specialized medicine First line medicine Clinical Application of the Concept of Risk Vascular, unstable Asymptomatic Vascular Diabetic Asymptomatic + risk factors Primary prevention Secondary prevention Diabetic + risk factors Pluri-vascular Low High Hyper Risk Symptomatic

35. 8/7/201535 Economic Burden of Coronary Artery Disease (CAD) US (2000)$118.2 billion USD Canada (1993)$19.6 billion CDN (15.2% of total economic burden of illness) UK (1996)£10 billion Germany (1996)112 billion DM Taiwan (1991)9.0-11.9 billion new Taiwan $ Sweden (1994)276 billion SEK Direct and Indirect Cost of CAD Country (not adjusted for inflation)

36. 8/7/201536 BMI <75%ile75-85%ile 85-95%ile at risk for ow >95%ile overweight Reaffirm healthy Habits; f/u annually Assess family history, food habits, activity Council to change food intake; increase physical activity Council to change food intake; increase physical activity Assess RF; If >1 RF, treat as >95%ile Assess RF; Treat RFs; Involve family Nesbitt SD et al Ethnicity & Disease 14;2004

37. 8/7/201537 Role of Cardiovascular Specialist  Education of other health care personnel  Advocate for heart healthy public policies  Treat individual patients, including children with significant risk factors.

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39. 8/7/201539 Conclusions The burden of global CVD is increasing The burden of risk factors is rising alarmingly in children and youth Cardiovascular specialists have an obligation to lead in prevention Educate, Advocate, Treat

40. 8/7/201540 Gracias!

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42. Questions for readers of Prevention of Cardiovascular Diseases: Begin in Childhood! lecture by Ruth Collins-Nakai (developed by Supercourse Team) At what age do we begin to see fatty streaks associated with atherosclerosis? What is the difference in risk from the lowest to highest risk factors Why should we intervene with children to prevent MIs 60 years later?