Slide 1

Cardiovascular Epidemiology: Definitions Historical Perspectives and Assessing Risk of CVD Recent trends and population differences in CHD and CHD risk factors

Slide 2

Deaths in Thousands A Total CVD B Cancer C Accidents D Chronic Lower Respiratory Diseases E Diabetes Mellitus F Alzheimers Disease Leading causes of death for all males and females (United States: 2004). Source: NCHS and NHLBI.

Slide 3

Percentage breakdown of deaths from cardiovascular diseases (United States:2004) Source: NCHS and NHLBI. Coronary Heart Disease Heart Failure Diseases of the Arteries Defects Rheumatic Fever/ Rheumatic Heart Disease Stroke High Blood Pressure Congenital Cardiovascular Other

Slide 4

Cardiovascular disease deaths vs. cancer deaths by age (United States: 2004). Source: NCHS and NHLBI.

Slide 5

Development of Atherosclerotic Plaques Normal Fatty streak Foam cells Lipid-rich plaque Lipid core Fibrous cap Thrombus Ross R. Nature. 1993;362:801-809.

Slide 6

Intraluminal thrombus Growth of thrombus Intraplaque thrombusLipid pool Blood Flow Atherosclerotic Plaque Rupture and Thrombus Formation Adapted from Weissberg PL. Eur Heart J Supplements 1999:1:T1318

Slide 7

PDAY: Percentage of Right Coronary Artery Intimal Surface Affected With Early Atherosclerosis PDAY= PDAY= Pathobiological Determinants of Atherosclerosis in Youth. Strong JP, et al. JAMA. 1999;281:727-735. Fatty streaks Raised lesions White 15-1920-2425-2930-34 0 10 20 30 Women 0 10 20 30 15-1920-2425-2930-34 Black Age (y) 0 10 20 30 White 15-1920-2425-2930-34 Men Black 15-1920-2425-2930-34 0 10 20 30 Intimal surface (%)

Slide 8

(Adapted from Glagov et al.) Coronary Remodeling NormalvesselMinimalCAD Progression Compensatory expansion maintains constant lumen Expansion overcome: lumen narrows SevereCADModerateCAD Glagov et al, N Engl J Med, 1987.

Slide 9

Most Myocardial Infarctions Are Caused by Low-Grade Stenoses Pooled data from 4 studies: Ambrose et al, 1988; Little et al, 1988; Nobuyoshi et al, 1991; and Giroud et al, 1992. (Adapted from Falk et al.) Falk E et al, Circulation, 1995.

Slide 10

Libby P. Circulation. 1995;91:2844-2850. Vulnerable Plaque Thin fibrous cap Inflammatory cell infiltrates: proteolytic activity Lipid-rich plaque Lumen Lipid Core Fibrous Cap Thick fibrous cap Smooth muscle cells: more extracellular matrix Lipid-poor plaque Stable Plaque Lumen Lipid Core Fibrous Cap Vulnerable Versus Stable Atherosclerotic Plaques

Slide 11

Correlation of CT angiography of the coronary arteries with intravascular ultrasound illustrates the ability of MDCT to demonstrate calcified and non-calcified coronary plaques (Becker et al., Eur J Radiol 2000) Non-calcified, soft, lipid-rich plaque in left anterior descending artery (arrow) (Somatom Sensation 4, 120 ml Imeron 400). The plaque was confirmed by intravascular ultrasound (Kopp et al., Radiology 2004)

Slide 12

Eccentric, lipid-rich Fragile fibrous cap Prior luminal obstruction < 50% Visible rupture and thrombus Constantinides P. Am J Cardiol. 1990;66:37G-40G. Features of a Ruptured Atherosclerotic Plaque

Slide 13

Clinical Manifestations of Atherosclerosis Coronary heart diseaseCoronary heart disease Stable angina, acute myocardial infarction, sudden death, unstable angina Cerebrovascular diseaseCerebrovascular disease Stroke, TIAs Peripheral arterial diseasePeripheral arterial disease Intermittent claudication, increased risk of death from heart attack and stroke American Heart Association, 2000.

Slide 14

Definitions CARDIOVASCULAR DISEASE or CVD includes CORONARY ARTERY DISEASE and other cardiac conditions (congenital, arrhythmias, and congestive heart failure)CARDIOVASCULAR DISEASE or CVD includes CORONARY ARTERY DISEASE and other cardiac conditions (congenital, arrhythmias, and congestive heart failure) CORONARY ARTERY DISEASE (CAD) or CORONARY HEART DISEASE (CHD) (often broadly referred to as ISCHEMIC HEART DISEASE (IHD): primarily myocardial infarction and sudden coronary death, broader definition may include angina pectoris, atherosclerosis, positive angiogram, revascularization, and myocardial infarctionCORONARY ARTERY DISEASE (CAD) or CORONARY HEART DISEASE (CHD) (often broadly referred to as ISCHEMIC HEART DISEASE (IHD): primarily myocardial infarction and sudden coronary death, broader definition may include angina pectoris, atherosclerosis, positive angiogram, revascularization, and myocardial infarction

Slide 15

Definitions (cont.) REVASCULARIZATION includes coronary artery bypass graft (CABG), percutaneous transluminal coronary angioplasty (PTCA), stent, and atherectomyREVASCULARIZATION includes coronary artery bypass graft (CABG), percutaneous transluminal coronary angioplasty (PTCA), stent, and atherectomy CEREBROVASCULAR DISEASE includes stroke (ischemic or hemorrhagic) and transient ischemic attack (TIA)CEREBROVASCULAR DISEASE includes stroke (ischemic or hemorrhagic) and transient ischemic attack (TIA) PERIPHERAL VASCULAR DISEASE includes carotid artery disease and intermittent claudicationPERIPHERAL VASCULAR DISEASE includes carotid artery disease and intermittent claudication SURROGATE MEASURES include: carotid intimal medial thickness (IMT), coronary calcium, angiographic stenosis, brachial ultrasound flow mediated dilatation (FMD)SURROGATE MEASURES include: carotid intimal medial thickness (IMT), coronary calcium, angiographic stenosis, brachial ultrasound flow mediated dilatation (FMD)

Slide 16

Prevalence of cardiovascular diseases in adults age 20 and older by age and sex (NHANES: 1999-2004). Source: NCHS and NHLBI. These data include coronary heart disease, heart failure, stroke and hypertension.

Slide 17

Prevalence of coronary heart disease by age and sex (NHANES :1999-2004). Source: NCHS and NHLBI.

Slide 18

Annual Number of Americans Having Diagnosed Heart Attack by Age and Sex ARIC: 1987-2000 Source: Extrapolated from rates in the NHLBIs ARIC surveillance study, 1987-2000. These data dont include silent MIs.

Slide 19

Annual Rate of First Heart Attacks by Age, Sex and Race ARIC: 1987-2000 Source: NHLBIs ARIC surveillance study, 1987-2000.

Slide 20

Prevalence of stroke by age and sex (NHANES: 1999-2004). Source: NCHS and NHLBI.

Slide 21

Prevalence of heart failure by age and sex (NHANES: 1999-2004). Source: NCHS and NHLBI.

Slide 22

Note: Hospital discharges include people discharged alive, dead and status unknown.. Hospital discharges for heart failure by sex (United States: 1979-2004). Source: NHDS, NCHS and NHLBI.

Slide 23

Cardiovascular disease mortality trends for males and females United States: 1979-2004). Source: NCHS and NHLBI. Cardiovascular disease mortality trends for males and females (United States: 1979-2004). Source: NCHS and NHLBI. 0

Slide 24

Source: NHLBI 2002 Chart Book on Cardiovascular, Lung, and Blood Diseases

Slide 25

Slide 26

Lifetime Risk of Coronary Heart Disease in the Framingham Study Men Women At age 40 years:48.6%31.7% At age 70 years:34.9%24.2% Lloyd-Jones et al. Lancet 1999; 353:89-92 ____________________________________________________________ ______________________________________________________________ _________________________________________________________________

Slide 27

First Coronary Events: Framingham Study Percent as Specified Event MyocardialAngina Sudden InfarctionPectoris Death AgeMen Women Men Women Men Women 35-64 43%28% 41% 59% 9% 4% 65-8455%44% 28% 41% 11% 7.4% Framingham Study 44 year follow-up. ____________________________________________________________ ________________________________________________________ ____________________________________________________________

Slide 28

Estimated 10-Year CHD Risk in 55-Year-Old Adults According to Levels of Various Risk Factors Framingham Heart Study A B C D A B C D Blood Pressure (mm Hg)120/80140/90140/90140/90 Total Cholesterol (mg/dL) 200 240 240 240 HDL Cholesterol (mg/dL) 50 50 40 40 Diabetes No No Yes Yes Cigarettes No No No Yes mm Hg = millimeters of mercury mg/dL = milligrams per deciliter of blood Source:Circulation 1998;97:1837-1847.

Slide 29

Estimated 10-Year Stroke Risk in 55- Year-Old Adults According to Levels of Various Risk Factors Framingham Heart Study ABCDEF Systolic BP*95-105130-148130-148130-148130-148130-148 DiabetesNoNoYesYesYesYes CigarettesNoNoNoYesYesYes Prior Atrial Fib.NoNoNoNoYes Yes Prior CVDNoNoNoNoNoYes Source: Stroke 1991;22:312-318. *BP in millimeters of mercury (mmHg)

Slide 30

ABCDEF Systolic BP*95-105130-148130-148130-148130-148130-148 DiabetesNoNoYesYesYesYes CigarettesNoNoNoYesYesYes Prior Atrial Fib.NoNoNoNoYes Yes Prior CVDNoNoNoNoNoYes Estimated 10-year stroke risk in 55-year-old adults according to levels of various risk factors (FHS). Source: Wolf et al., Stroke.1991;22:312-318. *BP in millimeters of mercury (mmHg)

Slide 31

Offspring CVD Risk by Parental CVD Status: Framingham Study Risk Ratio 2.5 2 1.5 1 0.5 0 MenWomen 1.0 1.7 2.2 1.0 1.7 Adjusted for: age, total/HDL Chol. ratio, SBP, smoking, diabetes, BMI Parental CVD