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Burden of disease

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(1)

CORONARY HEART DISEASE

Dr. Urfi

(2)

Definition

• Impairment of heart function due to inadequate blood flow to the heart compared to its needs, caused by obstructive changes in the coronary circulation to the heart

• Modern epidemic

• Responsible for 25-30% of deaths in most industrialized countries

• Not an unavoidable attribute

(3)

Spectrum

• Angina pectoris

• Myocardial infarction

• Irregularities of heart

• Cardiac failure

• Sudden death

Has variable course of natural history

(4)

Burden of disease

• CVDs are the number 1 cause of death globally: more people die annually from CVDs than from any other cause

• An estimated 17.9 million people died from CVDs in 2016, representing 31% of all global deaths. Of these deaths, 85% were due to heart attack and stroke

(5)

Proportional mortality ratio: 30% of all deaths in males and 25% in females

Loss of life expectancy: average gain would be from 3.4 years to 9.4 years for males

CHD incidence rate

Age specific death rate

Prevalence rate

Case fatality rate (within 28 days of onset)

Measurement of risk factor levels

Medical care

(6)

Epidemicity

• Epidemics began at different times in different countries

• United States-began in 1920s; declined by 1968

• Britain-1930s

• Other European countries-still later

• CHD is still the single most frequent cause of death among men < 65 years

• Highest mortality in European regions followed by South-East Asia region

• Japan-lowest incidence in developed world

(7)

India

• Single most important cause of death (2015)

• Steep increase in urban areas as compared to rural areas

• Prevalence: Urban (6.4%); Rural (2.5%)

• Overall prevalence -37/1000

• According to medical certification of cause of death in India-25.1% of all urban deaths are due to CHD

• Mortality rate due to IHD: 132/ lac population

(8)

IHD among South Asians

• Tends to occur at an earlier age; mean age of onset is almost a decade earlier

• Females: Males ratio higher as compared to developed world

• Case-fatality is higher

• Occurs in presence of normal or near normal levels of conventional coronary risk factors

(9)

Risk factors

• Aetiology is multifactorial

Non-modifiable Modifiable

Age Cigarette smoking

Sex High blood pressure

Family history Elevated serum cholesterol Genetic factors Diabetes

Personality Obesity

Sedentary habits Stress

(10)

Smoking

Major risk factor; doubles the risk

25% of CHD deaths in <65 years male

Important cause of sudden death in <50 years male

Risk is directly related with no. of cigarettes smoked per day

Independent risk factor as well as synergistic with other risk factors

Risk of death decreases substantially within one year of quitting and by 10-20 years is same as non-smoker

MI patients- fatal recurrence is reduced by 50%

(11)

Smoking

Mechanism s

CO induced atherogenesis

Nicotinic + of adrenergic drive

raising BP and Oxygen drive Lipid metabolism

with fall in protective HDL

(12)

Hypertension

• Single most useful test for identifying individuals with high risk

• Accelerates atherosclerotic process (more so if hyperlipidaemia is present)

• Systolic BP is better predictor of CHD

• Treating raised BP reduces risk of MI by 16%

(13)

Serum cholesterol

Elevation associated with increased risk of MI and CHD as whole

Triangular relationship between habitual diet, blood cholesterol-lipoprotein levels and CHD

Threshold level: 220 mg/dl or more

LDL (apolipoprotein-B) is most directly related with CHD

VLDL is more important for peripheral vascular disease than CHD

HDL (apolipoprotein A-I) is protective

Total cholesterol/HDL ratio of <3.0 is the clinical goal for CHD prevention

(14)

Diabetes:

• Risk of CHD is increased to 2-3 times

• CHD accounts for 30-50% of deaths in diabetics >40 years of age

Genetic factors:

• Positive family history increases the risk

• Most important determinants of individual’s TC and LDL levels

(15)

Physical activity:

• Sedentary life-style

• Regular physical activity increases HDL and decreases body weight and blood pressure

Hormones:

• Hyperestrogenemia leads to atherosclerosis ---->CHD, Stroke, Peripheral vascular disease

(16)

Type A personality:

• Type A > Type B personality

• Associated with competitive drive, restlessness, hostility, urgency, impatience

Alcohol:

• High alcohol intake (75 gm or more per day)

(17)

Oral contraceptives:

• Higher systolic and diastolic BP

• Higher risk of MI

Miscellaneous:

• Possible role of dietary fibre, sucrose, soft water, dysnoea on exertion and low vital capacity

(18)

Prevention

A. Population strategy

• i.

Prevention in whole population

• ii. Primordial prevention in whole population

B. High risk strategy

C. Secondary prevention

(19)

A. Population strategy

Principle:

Small changes in risk factor levels in total populations can achieve the biggest reduction in mortality

Aim:

To shift the whole risk factor distribution in the direction of “biological normality”

(20)

Specific interventions:

1. Dietary changes:

• Reduction in fat intake to 20-30% of total energy intake

• Saturated fat <10% of total energy intake

• Dietary cholesterol <100mg per 1000 kcal per day

• Increase in complex carbohydrate

• Avoid alcohol

• Daily salt intake to 5gm or less

(21)

2. Smoking:

To achieve smoke free society

Effective information and education activities, fiscal measures and smoking cessation programmes

3. Blood pressure:

Even a small reduction in average BP (2 or 3 mm Hg) would produce a large reduction in incidence in cardiovascular complications

Aim is to reduce the mean population BP levels

4. Physical activity:

(22)

Primordial prevention:

• Particularly important for developing countries

• Preventing the emergence and spread of CHD risk factors

• Aim is to change the community as a whole, not individuals subject

(23)

B. High risk strategy

i. Identifying risk

• BP measurement

• Serum cholesterol

• Those who smoke

• Family h/o CHD

• Diabetes

• Obesity

• Young women on OCPs

ii. Specific advice

• Preventive care

• Motivation to take

positive action against all identified risk factors

(24)

Disadvantage of high risk strategy

Intervention (treatment) may be effective in reducing the disease in a high risk group,

But it may not reduce the disease to the same extent in the general population, which consists of symptomatic, asymptomatic, high risk, low-risk and healthy people

More than half of CHD cases occur in those who are not apparently at special risk

(25)

C. Secondary prevention

To prevent recurrence and progression of disease

25% of those who suffer from acute MI die within 1 hour & would never reach the hospital; another 8-10% would die in next 24 hours in the hospital; among survivors 10% die within first year

Drugs (role of beta-blockers)

Surgery (CABG, PTCA)

Preventive measures- Cessation of smoking, control of BP and diabetes, healthy nutrition, exercise promotion

(26)

WHO Response

• All Member States ( 194 countries) agreed in 2013 on global mechanisms to reduce the avoidable NCD

burden including a "Global action plan for the prevention and control of NCDs 2013-2020“

• This plan aims to reduce the number of premature deaths from NCDs by 25% by 2025 through nine voluntary global targets

(27)

National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular

Diseases and Stroke (NPCDCS)

• Launched in 2010 in 100 districts across 21 States, in order to prevent and control the major NCDs

The main focus of the programme is on:

Health promotion, Early diagnosis,

Management and referral of cases,

Strengthening the infrastructure and capacity building

(28)

Main strategies of NPCDCS

Health promotion through behavior change

Outreach Camps are envisaged for opportunistic screening at all levels in the health care delivery system

Management of chronic Non-Communicable diseases, especially Cancer, Diabetes, CVDs and Stroke through early diagnosis, treatment and follow up through setting up of NCD clinics.

(29)

• Build capacity at various levels of health care

• Provide support for diagnosis and cost effective

treatment at primary, secondary and tertiary levels of health care

• Provide support for development of database of NCDs

(30)

Thank you….

References

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