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Prevention of Cardiovascular Diseases: Begin in Childhood!. Ruth Collins-Nakai MD, MBA, FRCPC, FACC President InterAmerican Society of Cardiology. Outline. World status of CVDs Argentinean status of CVDs Prevention efficacy Recommendations re risk factors

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prevention of cardiovascular diseases begin in childhood

Prevention of Cardiovascular Diseases: Begin in Childhood!

Ruth Collins-Nakai

MD, MBA, FRCPC, FACC

President

InterAmerican Society of Cardiology

outline
Outline
  • World status of CVDs
  • Argentinean status of CVDs
  • Prevention efficacy
  • Recommendations re risk factors
  • Role of CV specialist in prevention
world status of cvd
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

1999 WHF "Impending Global Pandemic of CVDs

slide6

Population per Physician

http://cvdinfobase.ic.gc.ca

slide8

Argentina

CVD mortality: females

http://cvdinfobase.ic.gc.ca

slide10

Argentina IHD mortality: males

http://cvdinfobase.ig.gc.ca

slide11

Argentina Diabetes: females males

http://cvdinfobase.ic.gc.ca

prevention facts
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

early appearance of atherosclerosis bogalusa heart study

80

60

40

20

0

Early Appearance of Atherosclerosis: Bogalusa Heart Study

Prevalence of Fibrous Plaque Lesions

80

Aorta

Coronary Arteries

60

%

40

20

0

2-15

16-20

21-25

26-39

2-15

16-20

21-25

26-39

Age (Years)

p = 0.001 for trend toward increasing prevalence with age in aorta

and coronary arteries.

the evidence
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
risk factors for atherosclerosis
Risk Factors for Atherosclerosis
  • Smoking
  • Obesity
  • High blood pressure
  • Physical Inactivity
  • High blood fat levels
  • Diabetes
  • Positive family history
  • Other (ethnicity, anger)
effect of multiple risk factors on probability of cad framingham study
Effect of Multiple Risk Factors on Probability of CAD: Framingham Study

40

21

10-Year % Probability of Event

14

10

6

4

SBP 150-160 + + + + + +

Cholesterol 6.2-6.8 - + + + + +HDL-C 0.8-0.9 - - + + + +Diabetes - - - + + +

Cigarettes - - - - + +

ECG-LVH - - - - - +

recommendations
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)
tobacco
Tobacco
  • Complete cessation for those who smoke
  • No exposure to environmental tobacco smoke
  • No new initiation of cigarette smoking or tobacco use
obesity
Obesity
  • Appropriate body weight (BMI for age)

(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
slide24

Trends in prevalence of overweight in USA

(CDC – NHANES)

%

1963-70

1971-74

1976-80

1988-94

1999

6-11 yrs

12-19 yrs

physical activity
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
lipids lipoproteins
Lipids & Lipoproteins
  • Total cholesterol <4.4 mmol/L recommended (USA>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
effect of sbp and dbp on age adjusted cad mortality mrfit
Effect of SBP and DBP onAge-Adjusted CAD Mortality: MRFIT

CAD Death Rate per 10,000 Person-years

80.6

48.3

43.8

38.1

37.4

34.7

31.0

25.3

25.8

25.2

24.9

24.6

23.8

160+

16.9

13.9

12.6

12.8

11.8

20.6

140-159

10.3

11.8

8.8

8.5

9.2

120-139

<120

100+

90-99

80-89

75-79

70-74

<70

Systolic BP (mmHg)

Diastolic BP (mmHg)

blood pressure
Blood Pressure
  • Systolic & diastolic BP>90th% for age, sex and height is abnormal (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)
diabetes
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)
other risk factors
Other Risk Factors
  • Ethnicity (esp. South Asian / aboriginal/black/Hispanic)
  • Low socioeconomic level
  • Social isolation
  • Depression
  • Pregnancy (HTN and gestnl diabetes)
  • “Emerging” risk factors
childhood abuse
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

slide34

Specialized medicine

Hyper

First line medicine

High

Risk

Low

Primary prevention

Secondary prevention

Clinical Application of the Concept of Risk

-

Vascular, unstable

Pluri-vascular

Diabetic + risk factors

Diabetic

Vascular

Asymptomatic + risk factors

Asymptomatic

Symptomatic

economic burden of coronary artery disease cad
Economic Burden of Coronary Artery Disease (CAD)

Direct and Indirect Cost of CADCountry (not adjusted for inflation)

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

slide36

BMI

<75%ile

75-85%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

role of cardiovascular specialist
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.
conclusions
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
slide42

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?