CARDIOVASCULAR DISEASE:
WHO IS AT RISK AND WHY?
Dr. Shakera R. Carroll
MBBS, DM, MCCFP
Family Medicine Physician
One Eleuthera Foundation
Cardiovascular Heart Matters
Pathway to Wellness Symposium
31.07.15
OUTLINE
Definition & scope
Impact
Pathophysiology
Risk Factors: classifications, choice and usage
Approach to patient involvement
Summarization
SPECTRUM OF CARDIOVASCULAR DISEASE
Coronary
Artery/Heart Disease
Cerebrovascular
Disease
Peripheral Arterial
Disease
Cardiomyopathy
Hypertensive Heart
Disease
Heart Failure
Cardiac Dysrythmias
Vascular Cardiac
IN THE BAHAMAS (2011)…
Ischaemic Heart Disease #2 cause of death: Men: 10%; 59.9/100,000, n=103
Women: 9.5%; 42.0/100,000, n=77
Hypertensive Diseases: Men: #3 – 9.6%, 57.5/100,000, n=99
Women: #1 – 14.4%, 63.3/100,000, n=114
Cerebrovascular Disease: Men: #5 – 5.8%, 34.9/100,000, n=60
Women: #3 – 8.7%, 38.2/100,000, n=70
Diabetes Mellitus: Men: #8 – 3.7%, 22.1/100,000, n=38
Women: #6 – 5.9%, 26.2/100,000, n=48
PATHOPHYSIOLOGY OF CARDIAC CVD
Figure 4 Impaired vasculogenesis and angiogenesis in IDCM
Roura, S. and Bayes-Genis, A. (2009) Vascular dysfunction in idiopathic dilated cardiomyopathy
Nat. Rev. Cardiol. doi:10.1038/nrcardio.2009.130
CARDIOVASCULAR RISK FACTORS
Age
Gender
Race
Dyslipidaemia
Hypertension
Hyperglycaemia
Smoking
Obesity
Physical Inactivity
Immutable/Non-
ModifiableModifiable
AGE
CVD is a “paediatric problem”
Russell Holman, 1961
Autopsies in 1950’s/1960’s
High prevalence of fatty streaks in large arteries of
children
77% Korean soldiers w/ advanced atherosclerosis
PDAY Research Group: extent of fatty streaks
and raised lesions increased with age
GENDER
Men > 45y, Women >55y
Heart Disease is the leading cause of death for women (e.g. 1 in 4 women will die from AMI compared to 1 in 5 men)
PDAY: Women had same extent of fatty streaks but only half the amount of raised lesions (plaques) as men
Women: Increased risk post menopause 2°decreased native estrogen & changes in BP, LDL, HDL
RACE/ETHNICITY
USA (2007): African American men 30% more
likely to die from heart disease than non-
Hispanic white men
40% more likely to have HTN and 10% less likely
to be controlled than white subjects
UK (2003): Afro-Caribbeans had 20-50% lower
risk of heart disease, but higher glycaemic and
lipid impairments compared to general
population
SMOKING
Considered most important factor re: risk
reduction
≥20 cigarettes/day 2 – 3-fold increased risk in
total heart disease
Endothelial damage and promotion of free-radical
formation
Appears to have greater adverse effects in
African American population
OBESITY/PHYSICAL INACTIVITY
Obesity:
associated w/ ↑ vascular risk, glucose intolerance,
insulin resistance, hypertension, physical inactivity
& dyslipidemia
Exercise is cardioprotective:
lowering blood pressure, lipids, and vascular
inflammation; improving endothelial dysfunction,
improving insulin sensitivity, and improving
endogenous fibrinolysis
reduces myocardial oxygen demand and increases
exercise capacity
HYPERTENSION
50 million Americans w/ HTN: almost 1/3 evade
Dx and only 1/4 receive effective Tx
HTN LVH (independent risk factor for CVD
morbidity/mortality)
High-normal BP ↑ 2-fold risk of CVD
DYSLIPIDAEMIA
Fatty streaks & raised lesions in large vessels increased with ↑ non-HDL & ↓HDL
Small, dense LDL : increased oxidation increase plaque formation
HYPERGLYCAEMIA
“Triple threat”
2002 survey: 68% pts w/ DM considered themselves at risk for stroke
Up to 97% of pts w/ DM have dyslipidaemia
Pts w/ DM have more small, dense LDL particles
DM endothelial dysfunction, diabetic autonomic neuropathy, decreased nitric oxide, increased levels of pro-inflammatory agents
IMPORTANCE OF IDENTIFYING CV RISK
FACTORS
Assignment of risk and
discussion/initiation/maintenance of appropriate
risk reduction strategies
SUMMARY
CVD has many types, causes and mechanisms of
injury
Significant morbidity and mortality is associated
with these groups of diseases
Understanding and identifying risk factors in
your patients and managing those risks (whether
globally or individually) is important in
decreasing the adverse consequences to person,
family and community
REFERENCES
Risk Factors for Coronary Artery Disease http://emedicine.medscape.com/article/164163-overview#showall
Specification and Costing of Services for Inclusion in the NHI Benefit Package, Recommendations for Provider Payment Mechanisms and Recommendations for Financing the NHI System in The Bahamas: Final Draft (2014)
Peter Libby, MD; Pierre Theroux. Basic Science for Physicians: Pathophysiology of Coronary Heart Disease. Circulation.2005; 111: 3481-3488 http://circ.ahajournals.org/content/111/25/3481.long
Henry C. McGill, et. al. Preventing Heart Disease in the 21st Century: Implications of the Pathological Determinants of atherosclerosis in Youth (PDAY) Study. Circulation.2008; 117: 1216-1227 http://circ.ahajournals.org/content/117/9/1216.full
About Heart Disease and Stroke. http://millionhearts.hhs.gov/abouthds/risk-factors.html
Menopause and Heart Disease. http://www.heart.org/HEARTORG/Conditions/More/MyHeartandStrokeNews/Menopause-and-Heart-Disease_UCM_448432_Article.jsp
Nish Chaturvedi. Ethnic Differences in Cardiovascular Disease. Heart. 2003 Jun; 89(6): 681–686. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1767706/
Betsy B. Dokken, PhD, NP, CDE. The Pathophysiology of Cardiovascular Disease and Diabetes: Beyond Blood Pressure and Lipids. Diabetes Spectrum July 2008 vol. 21 no. 3 160-165. http://spectrum.diabetesjournals.org/content/21/3/160.full
REFERENCES
Anthony J. Viera, MD, MPH; Stacey L. Sheridan, MD, MPH. Global Risk of Coronary Heart Disease: Assessment and Application. Am Fam Physician. 2010 Aug 1;82(3):265-274. http://www.aafp.org/afp/2010/0801/p265.html
U.S. Preventive Services Task Force. Using Nontraditional Risk Factors in Coronary Heart Disease Risk Assessment: Recommendation Statement. Am FamPhysician. 2011 Feb 15;83(4):441-443. http://www.aafp.org/afp/2011/0215/p441.html
New CVD Risk-reduction Model Promises to Pay for Results. http://www.aafp.org/news/health-of-the-public/20150604cvdriskmodel.html
2013 CV Risk Calculator. https://my.americanheart.org/professional/StatementsGuidelines/Prevention-Guidelines_UCM_457698_SubHomePage.jsp
http://www.acc.org/tools-and-practice-support/mobile-resources/features/2013-prevention-guidelines-ascvd-risk-estimator
Risk Calculations: Samples
http://tools.acc.org/ASCVD-Risk-Estimator/
http://www.mdcalc.com/framingham-coronary-heart-disease-risk-score/
REFERENCES
https://www.ffipo.org/wp-content/uploads/2012/10/CardiovascularDisease2.jpg
https://ak47boyz90.files.wordpress.com/2009/08/picture319.jpg?w=510
http://www.thrombosisjournal.com/content/2/1/12/figure/F1?highres=y
http://www.nature.com/nrcardio/journal/v6/n9/fig_tab/nrcardio.2009.130_F4.html
http://annals.org/article.aspx?articleid=744972#t1-10