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

DEFINITION

Disease of the heart and blood vessels

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 CARDIOVASCULAR

DISEASE

PATHOPHYSIOLOGY OF CVD

PATHOPHYSIOLOGY OF ATHEROSCLEROTIC

CVD

PATHOPHYSIOLOGY OF ATHEROSCLEROTIC

CVD

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 DISEASE RISK FACTORS

RISK FACTORS FOR CVD

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

RISK ASSESSMENT

FRAMINGHAM RISK SCORE: MEN

FRAMINGHAM RISK SCORE: WOMEN

OTHER SCREENING TOOLS

SCREENING TOOL COMPARISON

Framingham ASCVD (ACC/AHA)

EMERGING RISK FACTORS

VETTING CRITERIA

NOTES ON EMERGING FACTORS

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

QUESTIONS???