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New Trends in Heart Disease. Prof Chu-Pak Lau Cardiology Division University of Hong Kong Queen Mary Hospital. Public Health Conference 6 March 2004. Global Burden of CVS disease Bonow RO et al Circ 2002; 106:1602-1605. CVS death toll : 14.7M in 1990 to 17M 1999

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New trends in heart disease

New Trends in Heart Disease

Prof Chu-Pak Lau

Cardiology Division

University of Hong Kong

Queen Mary Hospital

Public Health Conference

6 March 2004


Global burden of cvs disease bonow ro et al circ 2002 106 1602 1605
Global Burden of CVS diseaseBonow RO et al Circ 2002; 106:1602-1605

  • CVS death toll :

    14.7M in 1990 to 17M 1999

  • Main burden due to CAD, is the leading cause of death worldwide (30%). CVA second leading cause

  • WHO : 1 Billion people overweight

    18M children <5 are overweight

  • 60% of the world population is physically inactive

  • DM : 150M people, will double in 2025

  • Tobacco consumption still increasing




Cad mortality in asian pacific men 100 000
CAD mortality in Asian-Pacific Statistics 1999(Men /100,000)


Cad mortality in asian pacific women 100 000
CAD mortality in Asian-Pacific Statistics 1999(Women /100,000)


Sino monica project circulation 2001 103 462 468 1
Sino-MONICA Project. Statistics 1999Circulation 2001; 103:462-468(1)

  • 7 Year project (1987-1993)

  • WHO project

  • Collaboration with BIHLBD


Sino monica project circulation 2001 103 462 468 2
Sino-MONICA Project. Statistics 1999Circulation 2001; 103:462-468(2)

  • Incidence and mortality of CVS disease is low but those of CVA were high

  • Great disparity in incidence

    CVS : 108.7/100,000 to 3.3/100,000 for men

    CVA : 553.3/100,000 to 33/100,000

    3. Geographical difference :

    North > South

    e.g. Beijing 70.3 vs Guangdong 59.7/100,000



Leading causes of death in us and hk female year 2000
Leading Causes of Death in US and HK (Female) Year 2000 Statistics 1999

Per

100,000

population


Special features of heart disease of women
Special Features of Heart Disease of Women Statistics 1999

  • Older

  • Delayed presentation

  • Higher mortality rate

  • Triple vessel disease and smaller vessel size

  • Higher CABG risk

  • Suboptimal response to PTCA

  • Despite a lower CAD risk, HK women have mortality from strokes comparable to the US


Modifiable risk factors
Modifiable Risk Factors Statistics 1999

Hypertension

Hypercholesterolemia

Diabetes mellitus

Homocysteine

C-Reactive Protein

Exercise

Obesity

Cigarette smoking


BP, Cholesterol and Stroke in Eastern Asia Eastern Stroke and Coronary Heart Disease Collaborative Research Group Lancet 1998; 352; 1801-1807


Serum cholesterol in urban cities of asia
Serum Cholesterol in Urban Cities of Asia and Coronary Heart Disease Collaborative Research Group Lancet 1998; 352; 1801-1807

Mg/dl


Global prevalence of diabetes
Global Prevalence of Diabetes and Coronary Heart Disease Collaborative Research Group Lancet 1998; 352; 1801-1807


Prevalence of diabetes and igt china
Prevalence of Diabetes and IGT China and Coronary Heart Disease Collaborative Research Group Lancet 1998; 352; 1801-1807


Obesity
Obesity and Coronary Heart Disease Collaborative Research Group Lancet 1998; 352; 1801-1807

Prevalence in the US in American white (1999-2000)

Obesity : BMI > 30

CDC 1999-2000


Mortality from cad in hk dept of health annual report 1997 2001 1
Mortality from CAD in HK and Coronary Heart Disease Collaborative Research Group Lancet 1998; 352; 1801-1807(Dept of Health Annual Report 1997-2001) (1)

No. of Pts


Mortality from cad in hk 45yrs dept of health annual report 1997 2001 2
Mortality from CAD in HK (<45yrs) and Coronary Heart Disease Collaborative Research Group Lancet 1998; 352; 1801-1807(Dept of Health Annual Report 1997-2001) (2)

% of Heath Disease <45 years

%


The Role of Platelets in Inflammation and Coronary Heart Disease Collaborative Research Group Lancet 1998; 352; 1801-1807and Plaque Stability

Activated platelets

Inflammatory modulators

CD40L

Platelet-derived growth factor

Platelet factor 4

RANTES

Thrombospondin

Transforming growth factor-

Nitric Oxide

Plaque rupture

& thrombosis

Libby P. Circulation 2001:103:1718-1720


Novel risk factors as predictors of peripheral arterial disease

Lipoprotein(a) and Coronary Heart Disease Collaborative Research Group Lancet 1998; 352; 1801-1807

Homocysteine

VCAM-1

Fibrinogen

LDL-C

ICAM-1

hs-CRP

TC:HDL-C

CRP + TC: HDL-C

0 1.0 2.0 4.0 6.0

Novel Risk Factors as Predictors of Peripheral Arterial Disease

Relative Risk of Incident Peripheral Arterial Disease

(Adjusted for age, smoking, DM, HTN, family history, exercise level, and BMI)

Ridker et al. JAMA 2001;285:2481-2485


Aha cdc recommendations for clinical and public health practice
AHA/CDC Recommendations for Clinical and Public Health Practice

Clinical Practice

  • Measurement of hs-CRP is an independent marker of risk and, in those judged at intermediate risk by global risk assessment (10%-20% CHD/10 yr) may help direct further evaluation & therapy in primary prevention of CHD. The benefits of such therapy based on this strategy remain uncertain. (Class IIa, Level of Evidence B)

  • Measurement of hs-CRP may be used at discretion of the physician as part of global risk assessment in adults without known CVD. The benefits of such therapy based on this strategy remain uncertain. (Class IIb, Level of Evidence C)

AHA/CDC Statement. Circulation 2003; 107:499–511


Hong kong cardiovascular risk factor prevalence study 2 crisps2

Hong Kong PracticeCardiovascular Risk Factor Prevalence Study-2 (CRISPS2)

Bernard Cheung

Department of Medicine

University of Hong Kong



Weight
Weight Practice

  • Body weight increased by 0.54±0.14 kg (p<0.001)

  • There was no significant change in body mass index (BMI)

  • Waist circumference increasedfrom 78.3±0.3 to 80.5±0.3 cm (p<0.001)



Bmi 25 is associated with diabetes or 3 1 2 0 4 7 and hypertension or 3 5 2 5 5 0
BMI Practice25 is associated with diabetes (OR 3.1 [2.0-4.7]) and hypertension (OR 3.5 [2.5-5.0])

Overweight, diabetes and hypertension


Conclusions
Conclusions Practice

  • In the CRIPS2 cohort, hypertension (27%), diabetes (15%), hypercholesterolaemia (46%) and overweight (35%) are common

  • As these risk factors can be modified by diet and lifestyle, the prevention of cardiovascular disease requires a community approach


Coronary Artery Disease Practice

  • Heart Failure

    Atrial Fibrillation


Heart failure how big is the problem really
Heart Failure : How Big is the Problem Really? Practice

  • 4,790,000 Americans have heart failure

    • Based on extrapolation of NHANES data

  • 550,000 new cases each year

    • Based on extrapolation of 44-year Framingham data

  • HF contributed to 287,200 deaths in 1999

    • Primary cause in 54,913

  • HF deaths have increased by 145% in 20years

    • Age-adjusted rates have not changed

    • Mortality rates may be declining

  • Hospital discharges increased from 377,000 to 962,000 between 1979 and 1999

    • Age adjusted rates and length of stay are declining


65+ Practice

45-64


A new epidemiology of ventricular dysfunction
A New Epidemiology of Ventricular Dysfunction Practice

The Old Epidemiology of CHF :

  • Included only symptomatic LV failure

  • Often excluded persons > 75 years old

  • Did not characterize ventricular function

    The New Epidemiology of Ventricular Dysfunction :

  • Includes assessment of ventricular structure and systolic / diastolic function

  • No age limits


Community Echo Survey of Systolic and Diastolic LV DysfunctionRedfield MM et al, JAMA 2003; 289: 194-202

Pts & Methods

1997-2000 : 2042 subjects of Olmsted County were screened with echo and Doppler, and followed for ~5yrs

Results

CHF : 2.2%

Systolic Dysfunction : 6%

EF > 50% : 44%

Diastolic Dysfu : Mild 20.6%

Mod 6.6%

Severe 0.7%


Pharmacotherapy
Pharmacotherapy Dysfunction

  • ACEI

  • Angiotensin II blockers

  • Betablockers

  • Aldosterone antagonist

  • Newer agents


Declining mortality in heart failure trial
Declining Mortality in Heart Failure Trial Dysfunction

Severe

Mild-Mod


Prevalence of heart failure with preserved ef
Prevalence of Heart Failure with Preserved EF Dysfunction

EF>

45%

EF>

50%

N=269

EF>

45%

N=338

EF>

40%

N=782

EF>

50%

N=137

EF>

50%

N=73


Main problems of electrical alterations
Main Problems of Electrical Alterations Dysfunction

1. PR prolongation (improper LV filling)

2. Interventricular asynchrony (RV-LV asynchrony)

3. Intraventricular asynchrony (regional LV asynchrony)

Results in :

1.  Stroke volume

2.  Contractility

3. MR


Before Dysfunction

After

CRT or Reverse Remodelling ?


Crt trials
CRT Trials Dysfunction

6m HW (m)

Echo (LVED in mm)

LVEF (%)

*Significant Improvement


Companion death or hf hospitalization of composite endpoints
COMPANION : Death or HF Hospitalization Dysfunction(% of composite Endpoints)

Bristow MR ACC 2003


Coronary Artery Disease Dysfunction

Heart Failure

  • Atrial Fibrillation


Af incidence resource implication
AF : Incidence/resource implication Dysfunction

In USA :

2 million; 160,000 new cases/yr

3-5% population >60yr

1.5 million primary reasons for consultation

1.4 million hospital discharges

130,000 A&E visits

6.6 billion US$ Medicare


Prevalence of af in elderly ryder benjamin ajc 1999
Prevalence of AF in Elderly DysfunctionRyder & Benjamin AJC 1999

(%)

Countries

Age (yrs)

USA

(70-80)

Netherlands

(70-80)

UK

(70-80)

Hong Kong

(60-94)

Japan

(>40)

Himalaya

(>15)


Af and mortality framingham heart study benjamin et al circulation 1998 98 946 952

Men : 1yr Cx Dysfunction

(%)

5

AF

No AF

4

3

2

1

0

CHD

CVA

Total

AF and Mortality : Framingham Heart StudyBenjamin et al Circulation 1998; 98:946-952

Methods :

5209 subjects, age 55-94, follow-up for 40yrs. AF documented by biennial ECG

Result :

AF increases mortality by 50% in men and 100% women

Conclusion :

Maintenance of sinus rhythm may decrease mortality



HF Dysfunction

AF


At af affect survival
AT/AF Affect Survival ? Dysfunction

Mortality (%)

Framingham2

SOLVD3

DIG4

VA-CHF5

MiddleKauff1

  • Middlekauff HR et al Circulation 1991; 84:40-48

  • Benjamin EJ et al Circulation 1998; 98:946-952

  • Dries DL et al JACC 1998; 32 : 695-703

  • Mathew J et al Chest 2000; 118: 914-922

  • Carlson PE et al Circulation 1993; 87 (supple) : VI 102-110


Emergence of new epidemics of cvs disease
Emergence of New Epidemics of CVS Disease Dysfunction

Two new epidemics of cardiovascular disease are emerging : heart failure and atrial fibrillation

E. Braunwald


Therapeutic strategies in af
Therapeutic Strategies in AF Dysfunction

Maintain SR

Rate Control

vs

  • Necessary for all therapy

  • Minimal S/E

  • Symptomatic benefit

  • EF

    ? ET

  • Theoretically sound

  • After restoring SR

  • EF

  • ET

  • atrial function

    ?  stroke


Affirm study n engl j med dec 2002 347 1825
AFFIRM Study : DysfunctionN Engl J Med Dec 2002; 347 : 1825


Strategies for af management in chf
Strategies for AF Management in CHF Dysfunction

  • Drug

  • Ablate & pace

  • Pulmonary vein ablation

  • Atrial defibrillators

  • Main cause of AF is HT


Global approach to reduce cvs cva death
Global Approach to Reduce CVS/CVA Death Dysfunction

  • International cooperation

  • Research and Education

  • Targeted primary prevention strategies

    e.g. tobacco use, hypertension control, affordable clinical algorithm

  • Advocacy e.g. World Heart Day

  • Availability of cost-effective meds


The hong kong ami registry 1995 1996 woo ks et al for the hk ami task force
The Hong Kong AMI Registry 1995-1996 Woo KS et al for the HK-AMI Task Force

Background :

A territory wide survey of all cases of AMI admitted into hospital. Initiated by the HK College of Cardiology

Subject and Methods :

A total of 3334 AMI (diagnosis by symptom, ECG and enzyme) were prospectively entered into a centralized data base, and uniformity and accuracy of data were audited by a research coordinator. In-hospital mortality complication were examined 96.2% were ethnically Chinese


Demographics of ami in hk 95 96
Demographics of AMI in HK (95-96) HK-AMI Task Force

Sex

Age

(%)

Sex

Age

Female

72.9 yrs

Male

64.8 yrs


Ami incidence mortality in us 1975 1995 goldberg rj et al circulation 1999 33 1533 1539
AMI Incidence & Mortality in US (1975-1995) HK-AMI Task ForceGoldberg RJ Et al Circulation 1999; 33: 1533-1539

Mortality (%)

Incidence /100,000


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