Post on 22-Jul-2020
Can We Prevent Coronary Artery Disease? Investing In Your Arteries!
Gresham Lecture, Museum of London January 2018 Professor John Deanfield, UCL
What can we expect in the future?
Investing in your arteries! Early action for Lifetime Risk reduction
Death Rates from All Circulatory Disease in England 1993-2011
Source: ONS (ICD9 390-459; ICD10 I00-I99)
Target:
40% minimum reduction
from 1995-97
B/L Progress target
A fall of 55% since baseline
0
20
40
60
80
120
140
160
180
Dea
th /
100
,000
pop
ulat
ion
100
Immortality Guaranteed by 2026
CVD: it’s not all over!
The Major Cause of Health inequality
Male: 77.7y Female: 85.5y
Male: 70.7y Female: 78.4y
0 20 40 60 Age (yrs)
Clinical Events
Genetic Environmental
Fetus
CVD Prevention Opportunity!
“Prevention Is
Better Than Cure”
Desiderius Erasmus
Roterodamus (28 October 1466 – 12 July
1536)
A Dutch Renaissance humanist, Catholic priest, social critic, teacher,
and theologian. He was born in Rotterdam and died in Basel.
Oil painting by Hans Holbein the Younger, 1523
Why Now? Economic
imperative Understanding
of disease Technology
advances
Forecasting Future CVD Costs in USA
Heidenreich Circ 2011; 123: 933-944
900 B
illio
ns 2
008
$
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
700
600
500
400
300
200
100
0
800
Indirect Direct >20% of cost of car from staff health insurance
Tuzcu Circ 2001 103:2075-10
32 Year Old Female
100
Ath
eros
cler
osis
(%)
17%
37%
60%
85%
71%
0
20
40
60
80
<20 20-29 30-39 40-49 ≥50 Age (years)
Most of us have Arterial Disease!
“The human race has had long experience and a fine tradition in surviving adversity; we now face a task for which we have little experience, the task of surviving prosperity”
Alan Gregg (1890-1957) Rockefeller Foundation
CVD Prevention: Challenge!
Modifiable Risk Factors: Prevention Opportunity
INTERHEART Lancet 2004
0
1
2
3
Odd
s R
atio
9 RFs accounted for 90% of MI in men and 94% in women
Age
Gender
Smoking
Cholesterol
BP
Diabetes
15152 MI patients in 52 countries
CV Risk Factors in Childhood and Carotid IMT in Adults
Raitakari et al JAMA 2003;290;2277-2283
Mea
n m
axim
um c
arot
id
IMT
(mm
) Risk factors measured at ages 12-18yrs
No. of risk factors
Men Women
P<0.001 P<0.001 0.88 0.80 0.72 0.64 0.56 0.48
0 1 2 3 or 4
Framingham Heart Study
Framingham Heart Study: Lifetime Risk A
djus
ted
Cum
ulat
ive
Inci
denc
e
50%
39%
27%
Attained Age
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0 50 60 70 80 90
69%
50% 46%
36%
5%
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0 50 60 70 80 90
8%
≥2 Major RFs 1 Major RF ≥ Elevated RF ≥ Not Elevated RF All Optimal RFs
Men Women
Lloyd-Jones Circ. 2006; 113: 791-798
Combined Effect of LDL-C and SBP on Cardiovascular Events
B. Ference (Plymouth, US), FP 3163
N = 14,368 Major Vascular Events
Effect of 1 mmol/L lower LDL-C & 10 mmHg lower SBP on Major Cardiovascular Events
SBP and LDL-C have independent, multiplicative and cumulative effects on CVD risk
0 0.25 0.50 0.75 1.00
Arterial disease causing heart attacks and strokes may be
largely preventable!
Never too Late: Never Too Early
“The most powerful
force in the universe is compound interest”
Albert Einstein (1879 - 1955)
Investment in Arterial Health
Knowledge
Communication
CVD Prediction and Prevention
Empowerment
Challenge of Communicating Risk and Benefit!
European Heart Journal 2012; 33: 1635-1701
Risk Management Based on Absolute CV Risk
Disenfranchises the Young, especially Women!
Non-smoking men <45yrs All women <65yrs
<10% 10yr CHD Risk
56% of US adults (87,000,000) have low (<10%) 10yr and high lifetime (≥39%) risk
Marma Circ Cardiothoracic Qual Outcomes 2010;3:8-14
Marma Circ 2009;120:384-390
Short Term v. Lifetime Risk in USA
JBS3 Lifetime Risk Calculator
Heart March 2014 and www.jbs3risk.com
JBS3 : Start of a new Process
Changes interactions with patients
Personalised approach
Empowers lifestyle
Not just a statin conversation!
Syst
olic
Blo
od P
ress
ure
(mm
Hg)
P<0.001
2
1
0
-1
-2
-3
-4
-5
Wei
ght (
kg)
P<0.001 1.0
0.8
0.6
0.2
-0.2
-0.4
-0.8
-1.0
0.4
0.0
-0.6
Glu
cose
(mg/
dl)
P<0.001 4
3
2
1
0
-2
-3
-4
-1
Tota
l cho
lest
erol
(mg/
dl)
P<0.001 8
6
4
2
0
-4
-6
-8
-2
Cur
rent
sm
okin
g (%
^)
P<0.001 2.0
1.5
1.0
0.5
0.0
-1.0
-1.5
-2.0
-0.5 Hea
rt A
ge (y
rs)
P<0.001 2.0
1.5
1.0
0.5
0.0
-1.0
-1.5
-2.0
-0.5
Impact of Heart Age Tool on Modifiable CVRFs 3153 subjects (47% male), Mean Age 46yrs, 12m FU
Lopez-Gonzalez European Journal of Preventive Cardiology 2015: 22; 389–396
Control FR HA
Heart Age NHS Calculator: 14/02/15-13/04/16 Total starts: 2,115,568 Total completes: 882,260
Ageing and Disease: What Gets You First?
Cholesterol
Obesity
Stress
BP
Smoking Systemic
Inflammation
Ageing Diabetes
Cancer CVD
Dementia
Ridker PM et al. Lancet 2017, 390:1833-1842
CANTOS: Additional Non-CV Clinical Benefits Incident Lung Cancer
D’Aiuto Lancet Diabetes 2017( in press)
Impact of Periodontitis Treatment on Glucose Control, Vascular and Renal Function in T2DM
• In UK population
• Severe in 5-10%
• Mild/mod in 40%
What’s Good for the Heart is Good
for the Brain!
CV RF lowering and Dementia Risk?
Whitmer Neurology 2005; 64: 277-281
Mid LifeCV RFs and Dementia 2.5
2.0
1.5
1.0
0.5
0 1 2 3 4
Haz
ard
Fact
or
Risk Factors CV composite Score
8845 HMO patients Age 40-43 yrs
Rovio JACC 2017; 69: 2279-2289
CV Risk Factors from Childhood and Later Cognitive Function (Young Finns Study)
National Initiative for Preventable Dementia Based on CV Risk Factor
Reduction
Multidomain Treatment and Cognitive Decline: FINGER Trial
Ngandu Lancet 2015; 385: 2255-2263
How Early Should Prevention Start? “Poor Start in Life”
Target Smoking and Obesity in the Young
Jha N Engl J Med 2013; 368: 341-50
Hazards of Smoking and Benefits of Smoking Cessation 113,752 w and 88,496 m aged ≥25y in US
NHIS
Probability of Obesity at 35yrs, according to current age, obesity status, and BMI
Ward et al, N Engl J Med 2017;377:2145-53
BMI during adolescence and CV mortality
Twig G et al, NEJM 2016;374:2430-40
Juonala NEJM 2011; 365: 1876-1885
Gortmaker et al. 2017, American Academy of Pediatrics 2017 National Conference
How to Prevent (Childhood) Obesity?
Review of data from 130,000 peer-reviewed publications and application of big data and microsimulation models to project the impact of interventions and their cost-effectiveness from 2015 to 2025
Jamie Oliver’s Healthy School Meals
Who is responsible for our health? Child? Parents? Government?
Doctors?
Responsibility for Childhood Obesity?
76 48 22 12 0
20
40
60
80
Parents Food and drink manufacturers
The individual The state
Who is at fault for obesity?
31 40 30 69
Who is reponsible for addressing it?
Henley Centre (2007)
‘Sell Health as a Valued Commodity’
Personalised Risk Prediction and Treatment
Identify individuals on accelerated
trajectory for CVD
FH in Children and Adolescents
Weigman Eur Heart J Apr 2015 HeFH:Start Statins at 8-10 yrs
Personalised Medicine: One size does not fit all!
Genetics
Imaging
Biomarkers
The Digital Health Revolution
Personalized Nutrition by Prediction of Glycemic Responses Zeevi Cell 2015; 163: 1079-1094
Althoff T, Nature July 2017
Analysis of Variations of Physical Activity Globally Smartphone data from >68m days of activity by 717,527 individuals
Joonseok Kim JACC 2017;69:7
Big Data, Health Informatics, and the Future of CV Medicine
Emergence of Health Maintenance as the Business of Health Care
‘Changing role of the doctor’ Asch NEJM 2012;367:888-9
Bankrupcy in 2012 after 131 yrs
Early Management / Digital Systems
Wellness
Illness
Revolution in the Delivery of Medicine
Ageing
“The Next Five Years for the NHS” : Simon Stevens, Chief Executive NHS England
“First, as a nation it’s time to get our act together on prevention…we’ve got a choice. Condemn our children to a rising tide of avoidable diabetes, cardiovascular disease, cancer? And burden taxpayers with an NHS bill far exceeding an extra £8 billion by 2020? Or take wide ranging action – as families, as the health service, as government, as industry. It’s a no brainer – pull out all the stops on prevention, or face the music.”
Speaking at a conference on 18 May 2015
Taxation of Food and Drink Sugar, rum and tobacco are commodities which are nowhere necessaries of life, which are become objects of almost universal consumption, and which are therefore extremely proper subjects of taxation. Adam Smith, The Wealth of Nations, 1776
Brownell NEJM 2009;360:1805-1808
Trends in Calories from Beverages
National tax of 1% per oz of drink $14.9 billion State tax Florida $928 million Alabama $221 million 72% approval for health promotion 2008 NYC poll
Brownell NEJM 2009;361:1599-1605
“It should be the function of medicine to have people die young as late as possible” Ernest L. Wynder M.D.
Final Thought…
CV Prevention- Long way to go! Focus more on lifetime management of
CV risk - like your savings! Engage the medical community, healthcare
providers, politicians and public to promote societal change
Better communication, especially with the young - use new risk tools to communicate ‘investment benefits’ (eg JBS3)
New technology and testing to deliver personalised medicine