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