Escolar Documentos
Profissional Documentos
Cultura Documentos
Textbooks
Definitions
CORONARY ARTERY DISEASE (CAD) or CORONARY HEART DISEASE (CHD) (often broadly referred to as ISCHEMIC HEART DISEASE (IHD): primarily myocardial infarction and sudden coronary death, broader definition may include angina pectoris, atherosclerosis, positive angiogram, and revascularization (perceutaneous coronary interventions, or PCI such as angioplasty and stents)
CARDIOVASCULAR DISEASE or CVD includes CHD, cerebrovascular disease, peripheral vascular disease, and other cardiac conditions (congenital, arrhythmias, and congestive heart failure)
Definitions (cont.)
SURROGATE MEASURES include: carotid intimal medial thickness (IMT), coronary calcium, angiographic stenosis, brachial ultrasound flow mediated dilatation (FMD) Hard endpoints include myocardial infarction, CHD death, and stroke
CVD and other major causes of death for all males and females (United States: 2007).
450,000 421,918 400,000 391,886
300,000
Deaths
250,000
200,000
150,000 79,827 100,000 66,689 61,235 35,478 21,800 0 A B C D E F A B D F C E 52,832 43,879 35,904
50,000
Males
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
1200
Procedures in Thousands
1000
800
600
400
200
Catheterizations
Bypass
PCI
Carotid Endarterectomy
Pacemakers
Note: Inpatient procedures only. Source: National Hospital Discharge Survey, NCHS, and NHLBI.
2011 American Heart Association, Inc. All rights reserved. Roger VL et al. Published online in Circulation Dec. 15, 2011
Direct and indirect costs (in billions of dollars) of major cardiovascular diseases and stroke (United States: 2008)
200 190.3
180
160
140
Billions of Dollars
120
100
80
60
40
20
Heart disease
Source: National Heart, Lung, and Blood Institute.
2011 American Heart Association, Inc. All rights reserved.
Hypertension
Stroke
Other CVD
Projected Total Costs of CVD, 20152030 (in Billions 2008$) in the United States
1200
1117.6
1000
886.2
800
704.7
564.9
600
408.5
400
245.2 194.1
223.8 186.7 250.5 97.0 74.1 44.6 57.0 69.1 143.0 111.2 87.1 197.8
320.0
200
156.9
2015
2020
2025
2030
550
Deaths in Thousands
Discharges in Millions
6 5 4 3 2 1 0 70 75 80 85 Years 90 95 00 06
Hospital discharges for cardiovascular diseases. (United States: 1970-2006). Note: Hospital discharges include
people discharged alive, dead and status unknown. Source: NCHS and NHLBI.
Prevalence of CVD in adults 20 years of age by age and sex (NHANES: 20052008)
100
90 80.1 80 72.6 70 Percent of Population 60 50 40 30 20 10 0 20-39 40-59 60-79 80+ 39.3 37.2 71.9 86.7
14.2 9.7
Men
Women
Source: NCHS and NHLBI. These data include CHD, HF, stroke, and hypertension.
2011 American Heart Association, Inc. All rights reserved. Roger VL et al. Published online in Circulation Dec. 15, 2011
Deaths in Thousands
800
600
400
200
Years
0 1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2008
1,000
Deaths in Thousands
831
0 <45 45-54 55-64 65-74 Ages CVD Cancer 75-84 85+ Total
CVD deaths vs. cancer deaths by age. (United States: 2006). Source: NCHS.
CVD and other major causes of death for all males and females (United States: 2008)
450,000 419,730 400,000 392,210
300,000
200,000
150,000 78,378 100,000 67,122 35,346 24,516 73,968 57,919 43,524 35,207
50,000
0 A B C D E F A B D F C E
Males
Females
Source: NCHS and NHLBI. A indicates CVD plus congenital CVD; B, cancer; C, accidents; D, CLRD; E, diabetes; and F, Alzheimer's disease.
2011 American Heart Association, Inc. All rights reserved. Roger VL et al. Published online in Circulation Dec. 15, 2011
14 12 10
8.2
Percent of Population
8 6 4
2.4
7.2
2
0.3
0.5
1.6
0 20-39 40-59
Age
60-79
80+
Men
Source: NCHS and NHLBI.
2011 American Heart Association, Inc. All rights reserved.
Women
14.8
14
Percent of Population
12 10
8.2
8 6 4
2.4
7.2
2
0.3 0.5
1.6
0 20-39 40-59
Age
60-79
80+
Men
Women
Coronary Heart Disease Stroke 14 7 7 17 4 HF* 51 High Blood Pressure Diseases of the Arteries Other
Percentage breakdown of deaths from cardiovascular diseases (United States: 2006) * - Not a true underlying cause.
Source: NCHS.
Percent of Population
16 14 12 10 8 6 4 2 0
13.8 12.2 9.3 4.8 2.2 0.1 0.2 20-39 1.2 60-79 Women 80+
40-59 Men
Prevalence of heart failure by age and sex (NHANES: 2005-2006). Source: NCHS and NHLBI.
700
Discharges in Thousands
Hospital discharges for heart failure by sex. (United States: 1979-2006). Source: NHDS/NCHS and NHLBI.
Note: Hospital discharges include people discharged alive, dead and status unknown.
Thrombus
Lipid core
PDAY: Percentage of Right Coronary Artery Intimal Surface Affected With Early Atherosclerosis
30 20 10 0 30 20 10 0
Men
Women
30 20 10
15-1920-2425-2930-34 Black
Age (y)
PDAY= Pathobiological Determinants of Atherosclerosis in Youth. Strong JP, et al. JAMA. 1999;281:727-735.
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.)
Coronary Remodeling
Progression
Compensatory expansion maintains constant lumen Expansion overcome: lumen narrows
Normal vessel
(Adapted from Glagov et al.) Glagov et al, N Engl J Med, 1987.
Minimal CAD
Moderate CAD
Severe CAD
Intraluminal thrombus
Blood Flow
Intraplaque thrombus Adapted from Weissberg PL. Eur Heart J Supplements 1999:1:T1318
Lipid pool
Fragile fibrous cap Prior luminal obstruction < 50% Visible rupture and thrombus
Lumen
Fibrous Cap
Lipid Core
Thin fibrous cap Inflammatory cell infiltrates: proteolytic activity Lipid-rich plaque
Thick fibrous cap Smooth muscle cells: more extracellular matrix Lipid-poor plaque
Correlation of CT angiography of the coronary arteries with intravascular ultrasound illustrates the ability of MDCT to demonstrate calcified and non-calcified coronary plaques (Becker et al., Eur J Radiol 2000)
Non-calcified, soft, lipid-rich plaque in left anterior descending artery (arrow) (Somatom Sensation 4, 120 ml Imeron 400). The plaque was confirmed by intravascular ultrasound (Kopp et al., Radiology 2004)
HDL cholesterol 60 mg/dL counts as a negative risk factor; its presence removes one risk factor from the total count.
Prevalence (unadjusted) estimates for poor, intermediate and ideal cardiovascular health for each of the 7 metrics of cardiovascular health in the AHA 2020 goals, US children aged 12-19 years, NHANES 2007-2008
Age-standardized prevalence for poor, intermediate and ideal cardiovascular health for each of the 7 metrics of cardiovascular health in the AHA 2020 goals, among US adults >20 years of age, NHANES 2007-2008
____________________________________________________________
Men
Women
31.7% 24.2%
_________________________________________________________________
____________________________________________________________
____________________________________________________________
Estimated 10-Year CHD Risk in 55-Year-Old Adults According to Levels of Various Risk Factors
Framingham Heart Study
40 35 30 25 20 15 10 5 0
Estimated 10-Year Rate (%)
37 25 20 13 5 5 8 27 Men Women
A
Blood Pressure (mm Hg) Total Cholesterol (mg/dL) HDL Cholesterol (mg/dL) Diabetes Cigarettes
mm Hg = millimeters of mercury mg/dL = milligrams per deciliter of blood
B
140/90 240 50 No No
C
140/90 240 40 Yes No
D
140/90 240 40 Yes Yes
120/80 200 50 No No
Estimated 10-Year Stroke Risk in 55Year-Old Adults According to Levels of Various Risk Factors
Framingham Heart Study
Estimated 10-Year Rate (%)
30 25 20 14.8 15 10 5 0 2.6 4 1.1 5.4 2 3.5 8.4 6.3 19.1 22.4 27
C
Men
D
Women
A 95-105 No No No No
B 130-148 No No No No
C 130-148 Yes No No No
2.5 2.5
2 2
2.2
1.5 1 1
1.0
1.7
1.7
1.7
1.0
0.5 0.5 0 0
Men MEN
Women WOMEN
Adjusted for: age, total/HDL Chol. ratio, SBP, smoking, diabetes, BMI
Risk imposed by a strong family history of heart attacks varies widely depending on the burden of modifiable risk factors
Multivariable Risk
9
Doubts about cholesterol as late as 1989
_______________________________________________________________________________
60 50 40
44 57
Cholesterol <200 mg 200-239 mg
>240 mg
Percent
30 20 10 0
34 29 19 33
Men
Women
Q1 (<182)
Q2 (182-202)
Q3 (203-220)
Q4 (221-244)
Q5 (>244)
Trends in mean total serum cholesterol among adolescents 1217 years of age by race, sex, and survey year (NHANES: 19881994*, 19992004 and 2005-2008).
180
175
174
170 165 165 163 161 160 159 157 155 155 154 166 163 161 163 162 160 158
158
150
145
140 NH White Males NH Black Males NH White Females NH Black Females Mex. Am. Males Mex. Am. Females
1988-94
1999-2004
2005-2008
Source: NCHS and NHLBI. NH indicates non-Hispanic. Mex. Am. indicates Mexican American. * Data for Mexican Americans not available.
2010 American Heart Association, Inc. All rights reserved. Roger VL et al. Published online in Circulation Dec. 15, 2010
Trends in mean total serum cholesterol among adults ages 20 by race and survey year, (NHANES: 19881994, 19992004 and 20052008).
210 206 205 205 203 204 201 200 198 198 201
185
1988-94
Source: NCHS and NHLBI. NH indicates non-Hispanic.
2010 American Heart Association, Inc. All rights reserved.
1999-2004
2005-2008
________________________________________________________
___________________________________________________________
most cases between the severity and duration of hypertension and development of cardiac complications. _______________________________________________________________
6% 4% 2% 0% Women
2.8 1.9 4.4
5.8
H.R. adjusted for age, BMI, Cholesterol, Diabetes and smoking *P<.001
Men
Prevalence of High Blood Pressure in adults 20 years of age by age and sex (NHANES: 20052008)
90 80 70 64.0 Percent of Population 60 50 40 30 20 11.1 10 0 20-34 35-44 45-54 Age 55-64 65-74 75+ 6.8 37.1 54.0 69.3 66.7 78.5
53.3
35.2
25.1 19.0
Male
Female
Source: NCHS and NHLBI. Hypertension is defined as SBP 140 mm Hg or DBP 90 mmHg, taking antihypertensive medication, or being told twice by a physician or other professional that one has hypertension.
2011 American Heart Association, Inc. All rights reserved. Roger VL et al. Published online in Circulation Dec. 15, 2011
90 80 70 60 50 40 30 20 10 0
78.8 79.0
Treatment NH Blacks
Extent of awareness, treatment and control of high blood pressure by race/ethnicity (NHANES : 2005-2006).
Source: NCHS and NHLBI.
_______________________________________________________________
CK Friedberg on Hypertension _______________________________________________________________ Diseases of the Heart 1966 Hypertension imposes a load on the heart which for many years may be compensated by left ventricular hypertrophy
_______________________________________________________________
Age-adjusted Rate per 1000 Age Men Women 35-64 164 135 65-94 234 235
Risk Excess Risk Ratio per 1000 Men Women Men Women 4.7*** 7.4*** 129 117 2.8*** 4.1*** 51 178
_____________________________________________________________
Biennial Rate per 1000. CVD=CHD, stroke, peripheral vascular disease, heart failure ***P<0.001
____________________________________________________________
CHD Risk by Cigarette Smoking. Filter Vs. Non-filter. Framingham Study. Men
<55 Yrs.
14-yr. Rate/1000
250 200
206 210
59
Prevalence of students in grades 9 to 12 reporting current cigarette use by sex and race/ethnicity (YRBSS, 2009)
25 22.3 22.8
19.4 16.7
15
10.7 10 8.4
Males
Females
Prevalence of current smoking for adults > 18 years of age by race/ethnicity and sex (NHIS: 2007-2009)
30
26.8 25 22.9 23.6
Percent of Population
20 17.9
15
10
9.3
5.4
0 Men Women
NH White
NH Black
Hispanic
Asian*
All percentages are age-adjusted. NH indicates non-Hispanic. *Includes both Hispanics and non-Hispanics. Data derived from Centers for Disease Control and Prevention/National Center for Health Statistics, Health Data Interactive.
2011 American Heart Association, Inc. All rights reserved. Roger VL et al. Published online in Circulation Dec. 15, 2011
Prevalence of current smoking for adults > 18 years of age by race/ethnicity and sex (NHIS: 2006-2008)
35 30.2 30
25 Percent of Population
24.0
20
15
10
9.4
4.5
0 Men Women
NH White
NH Black
Hispanic
Asian*
Source: CDC/NCHS, Health Data Interactive. All percentages are age-adjusted. NH indicates non-Hispanic. * Includes both Hispanics and non-Hispanics.
2010 American Heart Association, Inc. All rights reserved. Roger VL et al. Published online in Circulation Dec. 15, 2010
Diseases of The Heart Charles K Friedberg MD, WB ________________________________________________________________ Saunders Co. Philadelphia, 1949
The proper control of diabetes is obviously desirable even though there is uncertainty as to whether coronary atherosclerosis is more frequent or severe in the uncontrolled diabetic ______________________________________________________________
Cardiovascular Event Coronary Disease Stroke Peripheral Artery Dis. Cardiac Failure All CVD Events
Age-adjusted Biennial Rate Age-adjusted Per 1000 Risk Ratio Men Women Men Women 39 21 1.5** 2.2*** 15 6 2.9*** 2.6*** 18 18 3.4*** 6.4*** 23 21 4.4*** 7.8*** 76 65 2.2*** 3.7***
Age-adjusted prevalence of physician-diagnosed diabetes in adults 20 years of age by race/ethnicity and sex (NHANES: 20052008).
16 14.3 14 12.7 12 11.0 Percent of Population 10 14.7
8 6.8 6 6.5
Male
Female
NH White
Source: NCHS and NHLBI. NH indicates non-Hispanic.
2010 American Heart Association, Inc. All rights reserved.
NH Black
Mexican American
Trends in diabetes prevalence in adults 20 years of age, by sex (NHANES: 19881994 and 20052008).
9
8.2 8 7 Percent of Population 7.9
6
5
5.4
5.4
3
2 1
2.3
0
Physician Diagnosed 1988-94 Undiagnosed 1988-94 Physician Diagnosed 2005-08 Undiagnosed 2005-08
Male
Female
Trends in the prevalence of obesity among US children and adolescents by age and survey year (National Health and Nutrition Examination Survey: 1971-1974, 1976-1980, 1988-1994, 19992002 and 20052008)
20
18
16 14 12 10 8 6.5 6 4.0 4 2 0 11.3 15.9
17.4 16.0
17.9
Percent of Population
10.5
6.1
5.0
6-11
Age (Years)
12-19
1971-1974
1976-1980
1988-1994
1999-2002
2005-2008
Data derived from Health, United States, 2010: With Special Feature on Death and Dying. NCHS, 2011.
2011 American Heart Association, Inc. All rights reserved. Roger VL et al. Published online in Circulation Dec. 15, 2011
Age-adjusted prevalence of obesity in adults 2074 years of age, by sex and survey year (NHES: 196062; NHANES: 197174, 197680, 198894, 1999-2002 and 2005-08)
40 36.2 35 33.3 34.0
30 Percent of Population
28.1
26.0
25
20.6
20
16.8
15.7 17.1
15
12.2 10.7
12.8
10
0 Men Women
1960-62
1971-74
1976-80
1988-94
1999-2002
2005-08
Data derived from Health, United States, 2010: With Special Feature on Death and Dying. NCHS, 2011.
2011 American Heart Association, Inc. All rights reserved. Roger VL et al. Published online in Circulation Dec. 15, 2011
Risk variables include bottom quintile for HDL-C and top quintiles for cholesterol, SBP, triglycerides and glucose
Prevalence of students in grades 912 who met currently recommended levels of PA during the past 7 days by race/ethnicity and sex (YRBS: 2009).
50 47.3 45 40 35 43.3 41.3
Percent of Population
10
5 0 Male Female
NH White
NH Black
Hispanic
Currently recommended levels is defined as activity that increased their heart rate and made them breathe hard some of the time for a total of at least 60 minutes per day on 5 of the 7 days preceding the survey. Source: MMWR Surveillance Summaries.1 NH indicates non-Hispanic.
2010 American Heart Association, Inc. All rights reserved. Roger VL et al. Published online in Circulation Dec. 15, 2010
Prevalence of regular leisure-time physical activity among adults > 18 years of age by race/ethnicity and sex (NHIS: 2009).
45 40.1
40 36.0 35 29.7 25.9 25 24.1 36.2
Percent of Population
30
20
15
10
0 Men Women
NH White
NH Black
Hispanic
Source: Pleis et al, 2010. NH indicates non-Hispanic. Percents are age-adjusted. Regular leisure-time physical activity is defined as 3 or more sessions per week of vigorous activity lasting at least 20 minutes or five or more sessions per week of light/moderate activity lasting at least 30 minutes.
2010 American Heart Association, Inc. All rights reserved. Roger VL et al. Published online in Circulation Dec. 15, 2010
Prevalence of students in grades 9 to 12 reporting current cigarette use by sex and race/ethnicity (YRBSS, 2009).
25 22.3 22.8
20
19.4 16.7
15
10.7 10 8.4
Males
Females
Risk Assessment
Count major risk factors For patients with multiple (2+) risk factors
Perform 10-year risk assessment
CHD in male first degree relative <55 years CHD in female first degree relative <65 years
Use Framingham scoring for persons with 2 risk factors* (or with metabolic syndrome) to determine the absolute 10-year CHD risk. (downloadable risk algorithms at www.nhlbi.nih.gov) Expert Panel on Detection, Evaluation, and Treatment of
High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.
Step 2: Total Cholesterol TC Points at at Points at (mg/dL) Age 20-39 70-79 <160 0 160-199 4 200-239 7 240-279 9 280 11 Step 3: HDL-Cholesterol HDL-C (mg/dL) 60 50-59 40-49 <40 Points -1 0 1 2 Points at Points at Points
Note: Risk estimates were derived the Framingham Heart Study, 5 3 a predominantly Caucasian population in Massachusetts, USA. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.
Points at
Points at
Points
Points at
Points at
Points
7 4 Note: Risk estimates were derived the Framingham Heart Study, a predominantly Caucasian population in Massachusetts, USA.
Points at
Points at
Points
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.
Step 1: Age
Men
Years
20-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79
Women
Points
-9 -4 0 3 6 8 10 11 12 13
Years
20-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79
Points
-7 -3 0 3 6 8 10 12 14 16
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
Women
79
TC (mg/dL)
<160 160-199 200-239 240-279 280
Note: TC and HDL-C values should be the average of at least two fasting lipoprotein measurements. 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
Step 3: HDL-Cholesterol
Men
HDL-C (mg/dL) 60 50-59 40-49 <40 Points -1 0 1 2
Women
HDL-C (mg/dL) 60 50-59 40-49 <40 Points -1 0 1 2
Note: HDL-C and TC values should be the average of at least two fasting lipoprotein measurements. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.
Women
Systolic BP (mm Hg) <120 120-129 130-139 140-159 160 Points Points if Untreated if Treated 0 0 1 3 2 4 3 5 4 6
Note: The average of several BP measurements is needed for an accurate measurement of baseline BP. If an individual is on antihypertensive treatment, extra points are added. 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
Men
at
Women
at 70-79 Nonsmoker Smoker Points at Points Age 60-69 0 2 Age 0 1 Age 20-39 Age 40-49 0 9 0 7
Note: Any cigarette smoking in the past month. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.
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
Note: Determine the 10-year absolute risk for hard CHD (MI and coronary death) from point total. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.
Examination:
Presentation
Height: 6 ft 2 in Weight: 220 lb (BMI 28 kg/m2) Waist circumference: 41 in BP: 150/88 mm Hg P: 64 bpm RR: 12 breaths/min
In 1992 he exercised 14 minutes in a Bruce protocol exercise stress test to 91% of his maximum predicted heart rate without any abnormal ECG changes. He started on a statin in 2001. But in Sept 2004, he needed urgent coronary bypass surgery.
Note: Determine the 10-year absolute risk for hard CHD (MI and coronary death) from point total. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.
Other clinical forms of atherosclerotic disease (peripheral arterial disease, abdominal aortic aneurysm, and symptomatic carotid artery disease) Diabetes Multiple risk factors that confer a 10year risk for CHD >20%
Age-Adjusted Death Rates for Coronary Heart Disease by Country and Sex, Ages 35-74, 1999
Age-Adjusted to European Standard Data for 1999 unless noted Source: NHLBI 2002 Chart Book on Cardiovascular, Lung, and Blood Diseases
Age-Adjusted Death Rates for Stroke by Country and Sex, Ages 35-74, 1999
Age-Adjusted to European Standard Data for 1999 unless noted Source: NHLBI 2002 Chart Book on Cardiovascular, Lung, and Blood Diseases
Change in Age-Adjusted Death Rates for Coronary Heart Disease by Country and Sex, Ages 35-74, 1990-1999
Men
Women
Change in Age-Adjusted Death Rates for Stroke by Country and Sex, Ages 35-74, 1990-1999
Men
Women
Age-Adjusted to European Standard Latest data year note in parentheses Source: NHLBI 2002 Chart Book on Cardiovascular, Lung, and Blood Diseases
Migrant Studies
Ni-Hon-San Study showed Japanese living in Japan to have the lowest cholesterol levels and lowest rates of CHD, those living in Hawaii to have intermediate rates for both, and those living in San Francisco to have the highest cholesterol levels and CHD incidence
Pyramid of Risk
Expected Shifts in Cholesterol Distribution from High-Risk, Population, and Combined Approaches