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Cardiovascular Disease from the Canadian and International Perspectives

Cardiovascular Disease from the Canadian and International Perspectives. Dr. Sonia Anand MD, PhD Professor of Medicine McMaster University. Canadian Heart Health Strategic –Action Plan. Overview. Global Burden of CVD Canadian Burden of CVD Ethnic Variations in Risk factors

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Cardiovascular Disease from the Canadian and International Perspectives

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  1. Cardiovascular Disease from the Canadian and International Perspectives Dr. Sonia Anand MD, PhD Professor of Medicine McMaster University Canadian Heart Health Strategic –Action Plan

  2. Overview • Global Burden of CVD • Canadian Burden of CVD • Ethnic Variations in Risk factors • Association between Risk factors and CVD • Strategies for Prevention • Call for Action

  3. CHANGE IN THE RANK ORDER OF DISEASE BURDEN FOR 10 LEADING CAUSES, WORLD, 1990-2020 (DALYS) 1990 2020 1. Lower resp infection 2. Diarrh diseases 3. Perinatal 4, Major depression 5. Coronary heart dis 6. Stroke 7. TB 8. Measles 9. Traffic accidents 10. Cong anomalies 1Coronary heart disease 2. Major depression 3. Traffic accidents 4. Stroke 5. COPD 6. Lower resp infections 7. TB 8. War 9. Diarrhoeal disease 10. HIV

  4. WorldwideDeaths from Cardiovascular Causes Millions of Deaths from Cardiovascular Disease Reddy K. N Engl J Med 2004;350:2438-2440

  5. Numbers with DM (Diagnosed) Diabetes Care 2004:1047

  6. Age-standardized mortality rates of CVD and Cancer in Canada Per 100,000 Statistics Canada CVD= IHD, CBVD, DM, ATH

  7. Canada’s Modifiable Risk Factors The Growing Burden of Heart Disease and Stroke in Canada 2003

  8. Comparing Ethnic Groups

  9. Mortality for CHD and Cancer Age 35 – 74(1979-1993) Sheth et al, CMAJ 1999

  10. Aboriginal Immigrants 24% 74% • 922,000 Chinese • 723,000 South Asians • 1,100,000 + Aboriginal people

  11. SHARE: Study of Health Assessment and Risk in Ethnic Groups Random Sample - Europeans, South Asians, Chinese, Aboriginal • Environmental • Factors • Lifestyle • Nutrition • Psychosocial • Cultural • Risk Markers • Lipids • Coagulation • Glucose • BP • Antioxidants • Homocysteine • Subclinical Disease • Carotid • Ankle Arm BP • LVH • Micro Alb. • Clinical • Events • CAD • Stroke • PVD Genetic Factors Anand S et al Can J Cardiol 1998

  12. Percent Distribution By Province ofRegistered Indian Population in Canada

  13. Overweight and Abdominal Fat % BMI ≥30; WHR > 0.85 (female)/1.0 (male) Age and sex Adjusted Anand et al SHARE Lancet 2000/1

  14. ↑ Glucose: Dysglycemia 11 Anand et al SHARE

  15. Relationship of Glucose Factor to BMI in Non-white ethnic groups BMI=21 BMI = 30 Razak et al Circ 2005

  16. CVD Prevalence comparing Ethnic Groups in Canada Anand et al SHARE Age and Sex Adjusted

  17. SHARE- Nutrition Anand et al SHARE

  18. SHARE- Fat Intake

  19. SHARE- Fish

  20. Risk of CVD and Social Disadvantage Aboriginal and South Asian ♂ Aboriginal and South Asian ♀ Chinese ♂/ ♀ Anand, S. S et al. Int. J. Epidemiol. 2006 35:1239-1245; doi:10.1093/ije/dyl163

  21. Changes in Risk Factors with Migration

  22. EVOLUTION OF RISK FACTORS IN URBAN MIGRANTS • ¯ Activity • Diabetes • ­ Calories • Dyslipidemia • Cultural Stressors • Hypertension ­ CVD

  23. INTERHEART: Design Cases: First Acute Myocardial Infarction (n=15,152) Controls: Matched to cases by age (+/-5 yr and sex) at each site (n=14,820) Data collected from 262 sites in 52 countries Coordinated by the Population Health Research Institute, McMaster University, Canada Ounpuu S et al Am Heart J 2001

  24. Risk Factor Frequency Varies Are the same risk factors important in all ethnic groups, age groups, and women and men?

  25. INTERHEART: Design Cases: First Acute Myocardial Infarction (n=15,152) Controls: Matched to cases by age (+/-5 yr and sex) at each site (n=14,820) Data collected from 262 sites in 52 countries Coordinated by the Population Health Research Institute, McMaster University, Canada Ounpuu S et al Am Heart J 2001

  26. INTERHEART: > 27,000 Cases and Controls

  27. INTERHEART Global Case-Control Study: Nine Modifiable Risk Factors • Smoking • Elevated Lipids: ↑ ApoB/Apo A ratio • Diabetes • Hypertension • Abdominal Obesity: ↑ Waist to Hip Ratio • Physical Activity: > 4 hrs/week • Alcohol: ≥ 3 drinks/week • Fruit and Vegetable Consumption: Daily • Psychosocial Stress: Work/home stress, depression, financial stress, locus of control • >27,000 subjects • 52 Countries • 6000 women • > 12,000 > age 60 yrs

  28. Risk of MI associated with Risk Factors in the Overall Population

  29. Risk Factors for Acute MI in the Overall Population Over 90% of AMI are predicted by these nine risk factors Lancet 2004

  30. 8 4 OR (99% CI) 2 1 INTERHEART: Apolipoprotein B/A-1 and MI Deciles: 1 2 3 4 5 6 7 8 9 10 Cont 1210 1206 1208 1207 1210 1209 1207 1208 1208 1209 Cases 435 496 610 720 790 893 1063 1196 1366 1757 Median 0.43 0.53 0.60 0.66 0.72 0.78 0.85 0.93 1.04 1.28

  31. 16 8 4 2 INTERHEART: Smoking and MI OR (99% CI) 1 Never 1-5 6-10 11-15 16-20 21-25 26-30 31-40 41+ Cont 7489 727 1031 446 1058 96 230 168 56 Cases 4223 469 1021 623 1832 254 538 459 218 OR 1 1.38 2.10 2.99 3.83 5.80 5.26 6.34 9.16

  32. Independent risk of MI associatedwith 2 markers of obesity WHR adjusted for age, sex, smoking, region … + BMI BMI - adjusted for age, sex, smoking, region …+ WHR

  33. INTERHEART DIETARY ANALYSIS • Methods • 6,530 cases and 10,792 controls • 19 items food groups questionnaire • Dietary Patterns: • Prudent diet: raw and cooked vegetables, legumes and fruits • Oriental diet: tofu, soy sauce and green leafy vegetables • Western diet: dairy, fried foods and meats (high in saturated fats)

  34. Dietary Intake Varies by Ethnicity Dietary Patterns: • Prudent diet: raw and cooked vegetables, legumes and fruits • Oriental diet: tofu, soy sauce and green leafy vegetables • Western diet: dairy, fried foods and meats (high in saturated fats) Iqbal et al 2006

  35. INTERHEART: Relative Risk of MI by Dietary Type ↑ 29% ↓ 24% • Adjustment factors • Age, sex, region, BMI, WHR, physical activity, alcohol intake, smoking, apoB/apoA1, psycho-social factors, and education Iqbal R et al 2006

  36. Risk factors the same, Frequency Varies Risk factors for MI are the same for all ethnic groups, young and old, and women and men.

  37. Association between Risk factors and CHD is similar btwn ethnic groups Disease Determinants Risk Factors Consistent btwn ethnic groups Environment Dyslipidemia Diet Quality Physical activity Stress Air Pollution Dysglycemia Adiposity Blood Pressure CHD Smoking Psychosocial Stress Genetic Factors Physical Inactivity ETOH

  38. Prevention and Treatment of Risk Factors/CVD

  39. Frequency of INTERHEART RISK Factors in Cases and Controls Number of Subjects Number of Interheart Risk Factors

  40. Risk Factors are Ubiquitous in the Population – We are all at Risk • 80% of Canadians have 1 Risk Factor • 30% of Canadians have 2 Risk Factors • 11% have 3 or more Risk Factors Source:    Statistics Canada, Canadian Community Health Survey

  41. INTERHEART: Decreased Risk of AMI with Avoidance of Smoking; Daily Fruits/Veg, Reg Phys Activity & Alcohol 0.35 0.70 0.86 0.91 0.24 0.21 0.19 1.0 All the “right” things reduce odds of AMI by 80% 0.5 OR (99% CI) 0.25 0.125 no smk Frt/Veg Exer Alc Nosmk+fvg +Exer +Alc

  42. RCT Evidence that Altering Risk Factors Lowers CHD Iestra et al Circulation 2005

  43. How can we prevent the majority of premature CHD? Can we prevent 90% of MI in young and middle age NOW? NO Can we prevent >90% of MI in young and middle age in the foreseeable future? YES

  44. Determinants of Risk Behaviours in a Population Individuals with Risk Factors for CVD Individuals with CVD GOAL Interventions with a Socio-Economic & Political Focus Interventions with a Preventive Focus Interventions with a Clinical Focus Type of Strategy • Lipid Lowering • Aspirin • Beta blockers • ACE-inhibitors • Appropriate revascularization Identifying & treating ↑ Cholesterol or Hypertension Smoking cessation • Taxing Tobacco • Subsidizing healthy foods • Promote Physical Activity by improving Built Environment Examples Prevention of Cardiovascular Disease - Individual Approach

  45. TREATMENT, 95% of Resources High- Risk Treatment Intervention Approaches Policy and Environmental Change Risk Factor Detection and Control Behavior Change Emergency Care or Acute Case Management Rehabilitation or Long-term Case Management End-of-Life Care PREVENTION, 5% of Resources

  46. Greatest Gains in Preventing CVD: Population Approach Optimal Distribution Present Distribution % of Population High Risk 10 Year Cardiovascular Disease Risk

  47. Swimming Upstream Simple Lifestyle Intervention Energy Saving Devices Fast Food Tobacco Advertising

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