Lifestyle and CVD risk

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2017-09-08

1

Acknowledgments/Disclosures

Speaking:

HT Canada , Sea Courses, Université Laval et McGill

Consulting Insurance :

La Capitale , SSQ-Ass, SSQ-Vie et l’Union -Vie

Guidelines :

Diagnosis et CV risk stratification, Canadian Hypertension

Guidelines

Continuous Professional Development :

AAIM ,CCS

2

• The information presented is based on recent information that

is explicitly ‘‘evidence-based’’ and

is based on CCS and HT Canada Guidelines,2016- 2017

Mitigating Potential Bias

3

Lifestyle and CVD Risk

• recognise lifestyle as « primordial » CVD risk factors.

• distinguish « alleged and proven » links between lifestyle

and CVD

• support lifestyle modification in clinical practice as the Rx for

classical ( primary ) CVD risk factors.

After participating to this session,

the attendees will…

No potential conflicts of interest

G.T. – D.D. 2017 4

Are other risk factors equally or

more effective at predicting CVD

Olsen, et al. Current Vascular Pharmacology, 2010, 8, 134-139

Genetics

Age

Gender

Lifestyle

Social status

Physical

activity

Alcohol

Smoking

Waist/

hip-ratio

BMI

Metabolic

factors

Lipids

Glucose

Haemodynamic

factors

Blood pressure

Heart rate

Preclinical desease

Atherosclerosis

Endothelial

dysfunction

Vascular stiffness

LV hypertrophy

LV dysfunction

CV disease

MI

Stroke

CV death

X

G.T. – D.D. 2017 5

Overview

Risk FactorsSuccess story

Smoking

Stress management

Physical Exercise

Nutrition

G.T. – D.D. 2017 6

CHD Mortality Rates in Men < 65 Years Old

Finland

France

Hungary

Japan

United Kingdom

USA

Mortality from ischaemic heart disease, men 0-64 years. Source: WHO HFA database.G.T. – D.D. 2017 7

Contribution of Risk Factors to Burden of

Disease Mortality*

*Based on The World Health Report 2003. Yach et al. JAMA. 2004;291:2616-2622.

Percentage of Mortality Attributable to Risk Factors

G.T. – D.D. 2017 8

Lifestyles & Characteristics Associated

with Increased Risk of Future CHD events

• Age

• Sex

• Family history of

premature CHD or other

atherosclerotic disease

at early age

• (man <55 years)

• (woman <65 years)

• Personal history of CHD

or other atherosclerotic

disease

• Elevated blood pressure

• Elevated LDL-cholesterol

• Low HDL-cholesterol

• Elevated triglycerides

• Hyperglycaemia/Diabetes

• Obesity

• Thrombogenic factors

• Diet high in saturated fat,

cholesterol and calories

• Tobacco smoking

• Excess alcohol

consumption

• Low physical activity

• Physical inactivity

Lifestyles « Treatable/Disease » Non modifiable

G.T. – D.D. 2017 9

The Finnish experience

• Some facts: 1960

• High initial population CVD and hypertension rates

• Some of the key actions

• Some monitoring and surveillance

• Part of a pilot (North Karelia) and then national program to

reduce CVD

• Multi sector collaboration

• Regulation (warning labels)

• Strong armed voluntary reduction in salt

• Salt substitute (Pan salt)

• Major newspaper engagement

• Strong key opinion leaders

G.T. – D.D. 2017 10

Finland: Serum Cholesterol

700/100 000 —> 300/100 000

1972 - 1992

1972 —> 1992 20 years

G.T. – D.D. 2017 11

Observed and predicted decline in mortality

from ischaemic heart disease in men aged 35-

64 in Finland

Vartiainen J et al. BMJ Vol 309 July 2, 1994

G.T. – D.D. 2017 12

Smoking

Quitting at any age is most beneficial

G.T. – D.D. 2017 13

Quitting at Any Age Increases Life Expectancy

Doll R et al. BMJ. 2004;328:1519–1527.

Quitting at a younger age is most beneficial

% Survival

From Age

40

Stopped Age

35-44

Non-smokers Cigarette Smokers

Years

72%

42%

- 30%

- 10 years(60y)

1

2

3

G.T. – D.D. 2017 14

Physicians and Smoking cessation counselling

Bupropion

Varenicline

Nicotine replacement Rx.

Express empathy, Offer Help

G.T. – D.D. 2017 15

Average number of cigarettes smoked per

day by household and workplace

Data source: 2003 Canadian Community Health Survey * Significantly higher than estimate for previous category(-

ies) (p < 0.05)

Men: - 39%

Women: - 37%

1916

1210

Average number of cigarettes smoked per

day by household and workplace smoking

restrictions and sex, employed daily

smokers aged 18 to 54, Canada excluding

territories, 2003.

G.T. – D.D. 2017 16

Year

Admissions, Acute MIHelena, Minnesota, (Scott County), USA

Sargent RP Shepard, Robert M, Glantz SA. Reduced incidence of admissions for myocardial

infarction associated with public smoking ban: before and after study. BMJ 2004;328:977-980

Admissions for acute myocardial infarction during 6 month periods, June-November 2002

before, during, and after the smoke-free ordinance. (Ordinance did not apply outside

Helena). The ordinance was implemented on June 5th, 2002 and then revoqued.

Helena

Outside Helena

1998 1999 2000 2001 2002 2003

60

50

40

20

10

0

30

G.T. – D.D. 2017 17

Risk Factor

Stress / Physical Exercise

G.T. – D.D. 2017 18

G.T. – D.D. 2017 19

Longevity and # heart beats

Adapted. Levine H.j » JACC 1997 ; 30 : 1104-6 GT, jan 2008

(10,000,000,000) 86 000 / day

G.T. – D.D. 2017 20

Longevity and # heart beats

G.T. – D.D. 2017 21

Physical Exercise

Meta-analysis: dose-response relation between physical activity and risk of coronary heart disease. The thick blue line

represents a fitted curve and the thin blue lines the confidence intervals. (From Sattelmair J, Pertman J, Ding EL, et al:

Doseresponsebetweenphysicalactivityandriskofcoronaryheartdisease:Ameta-analysis.Circulation124:789,2011.)

G.T. – D.D. 2017 22

Risk Factor

Nutrition

G.T. – D.D. 2017 23

Risk Factor

CHOLESTEROL

G.T. – D.D. 2017 24

« Normal » cholesterol

3.9

2.6

1.3

Physiologic LDL-C

from receptor studies

: .66

Humans, NA

Average Adults

New borns

LDL.

C

Rat

Guinea Pig

Sheep

Cow

CamelRabbit

Pig

25

Change of Diet Pattern

Traditional Low fat

G.T. – D.D. 2017 26

Osmo Turpeinen, et al. Journal of Epidemiology Vol 8. No 2; 1979.

Dietary Prevention of CHDFinnish mental hospital (1959-1971)

Serum Cholesterol over a period of 10 years

Practically total replacement of dairy fats by vegetable oils

in the diets of these two hospitals

G.T. – D.D. 2017 27

Osmo Turpeinen, et al. Journal of Epidemiology Vol 8. No 2; 1979.

Dietary Prevention of CHDFinnish mental hospital (1959-1971)

« Practically total replacement of dairy fats by vegetable oils in the diets of these two

hospitals… The total fat consumption should be reduced from the present high levels of 40-

45% of total food energy to 35% or even to 25% of total food energy. Less saturated fats. »

Hospital N Hospital K

First period

1959 - 1965Experimental Diet Normal Diet

Second period

1965 - 1971Normal Diet Experimental Diet

CHD

Normal Diet Experimental Diet

Hospital N 13,0 5,7

Hospital K 15,2 7,5N and K, mean 14,1 6,6

Age-ajusted Death Rates from Coronary Heart Disease

per 1 000 Person - Years - Males

Less saturated fats

G.T. – D.D. 2017 28

Mediterranean Diet Dietary Patten

http://www.mdpi.com/1422-0067/15/7/11678/htm

G.T. – D.D. 2017 29

Mediterrean Diet (Post MI)

de Lorgeril et al. (Circulation. 1999;99:779-785

Cumulative survival without nonfatal infarction, without major secondary

end points, and without minor secondary end points.

Lyon Heart Study

G.T. – D.D. 2017 30

Lyon Heart Study

15

10

5

0

Event

Rate

(%)

Death Cardiac

Mortality

Non Fatal

MI

Cancer

de Lorgeril et al. (Circulation. 1998;158 :1161; Circulation 1999;99 .

-56%

p=.03

-65%

p=.01

-70%

p=.01-61%

p=.05

Control diet

Mediterranean diet

24

19

25

17

6

14

8 7

G.T. – D.D. 2017 31

From Science to Action!

http://www.middleeartholiveoil.com

G.T. – D.D. 2017 32

Primary Prevention of CV Disease with a

Mediterranean Diet

Estruch et al. N ENGL J MED 368;14 NEJM.ORG APRIL 4, 2013

PREMIMED Study

A total of 7447 persons were enrolled (age range, 55 to 80 years); 57% were women.

The two Mediterranean-diet groups had good adherence to the intervention, according to self-

reported intake and biomarker analyses.

… free provision of extra-virgin olive

oil, mixed nuts, or small nonfood gifts.

G.T. – D.D. 2017 33

Mediterranean dietRecommended Goal

Olive oil * ≥4 tbsp/day

Tree nuts and peanuts ≥3 servings/wk

Fresh fruits ≥3 servings/day

Vegetables ≥2 servings/day

Fish (especially fatty fish), seafood ≥3 servings/wk

Legumes ≥3 servings/wk

Sofrito‡ ≥2 servings/wk

White meat Instead of red meat

Wine with meals (optionally, only for habitual drinkers) ≥7 glasses/wk

Discouraged Goal

Soda drinks <1 drink/day

Commercial bakery goods, sweets, and pastries <3 servings/wk

Spread fats <1 serving/day

Red and processed meats <1 serving/day

Low-fat diet (control)Recommended Goal

Low-fat dairy products ≥3 servings/day

Bread, potatoes, pasta, rice ≥3 servings/day

Fresh fruits ≥3 servings/day

Vegetables ≥2 servings/day

Lean fish and seafood ≥3 servings/wk

DiscouragedVegetable oils (including olive oil) ≤2 tbsp/day

Commercial bakery goods, sweets, and pastries ≤1 serving/wk

Nuts and fried snacks ≤1 serving /wk

Red and processed fatty meats ≤1 serving/wk

Visible fat in meats and soups. Always remove

Fatty fish, seafood canned in oil ≤1 serving/wk

Spread fats ≤1 serving/wk

Sofrito ≤2 servings/wk * Extra Virgin Olive Oil: EVOO

Estruch et al. N ENGL J MED 368;14 NEJM.ORG APRIL 4, 2013G.T. – D.D. 2017 34

Primary Prevention of CV Disease with a

Mediterranean Diet

N ENGL J MED 368;14 NEJM.ORG APRIL 4, 2013

EVOO: Extra Virgin Olive Oil

G.T. – D.D. 2017 35

Primary Prevention of Metabolic syndrome

with a Mediterranean Diet

Arch Intern Med. 2008;168(22):2449-2458

MetS: Metabolic Syndrome

MetS Reversion

MetS Incidence

G.T. – D.D. 2017 36

Cumulative diabetes free-survival

Salas-Salvadó J. et al. Reduction in the Incidence of Type 2 Diabetes With the Mediterranean Diet. Diab Care, volume 34, 14-19 2011

MedDiet

+

MedDiet

+

Traditional

G.T. – D.D. 2017 37

Incidence of diabetes or cardiovascular

end point, %

Salas-Salvadó J. et al. Reduction in the Incidence of Type 2 Diabetes With the Mediterranean Diet. Diab Care, volume 34, 14-19 2011

Traditional

G.T. – D.D. 2017 38

Primary Prevention of CV Disease

with a Mediterranean Diet

Pharmacological Research 65 (2012) 577-583

LFD: Low Fat Diet; Med-Diet : with Olive oil; Med Diet with Nuts

G.T. – D.D. 2017 39

Primary Care

Applicability

G.T. – D.D. 2017 40

Theoretical famework « suggested » for

treatment of obesity

Source: The ESC Handbook. Preventive Cardiol p81. 2016G.T. – D.D. 2017 41

G.T. – D.D. 2017

From Yarnall and Coll 2009. Cited in Profession Santé, Janvier 2015, Volume 1, No. 1

Time required for the practitioner to fully

implement practice guidelines developed by

learned societies

Acute

care

Chronic

care

Preventive

care

3,7 h 3 h 1,3 h

On average, a family physician spends

3,7 h 10,6 h 7,4 h

21,7 hours / day

If he had to follow all clinical practice guidelines, he would spend

8 hours

21,7 hours

Acute

care

Chronic

care

Preventive

care

42

Change4LIFE Initiative in the United Kingdom

G.T. – D.D. 2017 43

• A prospective single centered randomized controlled trial.

• New guidelines for secondary prevention in coronary artery

disease were distributed by mail and presented at a common

lecture for all general practitioners and specialists in 1995

• Two primary health care clusters were matched and

randomised to Intervention (I) or Control (C)

Pr Gunilla Hedlin ,Center for Allergy Research

Study desing

44

Trial profile

45

Secondary preventive local guidelines for

patients with CHD in 1995 ,Target goals :

• Total cholesterol < 5.0 mmol

• LDL-cholesterol < 3.5 mmol/l

• HDL-cholesterol > 1.0 mmol/l

• F-Triglycerids <2.3 mmol/l

• Stop smoking

• Diastolic blood pressure <95 mmHg)

• Blood sugar control

• Improved Quality of life by healthy food intake, weight reduction,

increased physical activity and stress reduction

24 % smokers

Tot chol 6,4 + 1,1

LDL-chol 4,2 + 1,0

46

• 44 % of the included patient in the control group had deceased

after ten years as compared to 22 % in the intervention group

(p= 0.0173; log rank test).

• Patients treated by a specialist deceased at a rate comparable

to the intervention group (23%).

Result after ten years

47

The CHAMP Initiative

The UCLA Medical

Center’s Cardiac

Hospitalization

Atherosclerosis

Management Program

(CHAMP) increases

guideline intervention and

reduced recurrent and

myocardial infarction.

Fonarow GC et al. Am J Cardiol 2001;87:819-822.

Guideline Intervention Use%

Post-CHAMP(1 year)

Beta-blocker

ACE Inhibitor

Aspirin

Statin

100

80

60

40

20

0Pre-CHAMP

92%

86%

61%

56%

78%

12%

6%

4%

64%

58%

CCB

G.T. – D.D. 2017 48

CHAMP study: Death or recurrent MI

Fonarow GC et al. Am J Cardiol 2001;87:819-822.

The UCLA Medical

Center’s Cardiac

Hospitalization

Atherosclerosis

Management Program

(CHAMP) increases

guideline intervention

and reduced recurrent

and myocardial

infarction.

14.8%

6.4%

0

5

10

15

20

Pre-CHAMP Post-CHAMP

%

G.T. – D.D. 2017 49

Lifestyle and CVD Risk

• recognise lifestyle as « primordial » CVD risk factors.

• distinguish « alleged and proven « links between lifestyle and

CVD

• support lifestyle modification in clinical practice as the Rx for

classical CVD risk factors ..

After participating to this session, the attendees will…

G.T. – D.D. 2017 50

Lifestyle and CVD risk

51