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LEARNING OBJECTIVES
Describe major & minor risk factors Enlist new emerging cardiovascular risk factors Describe prevention of cardiovascular diseases in relation to risk factors Describe prevention of HTN in according the level of prevention.

THE WORLD HEALTH IS IN TRANSITION

Epidemiological : NCDs overriding infectious diseases and double burden of diseases in many developing countries

Lifestyles: tobacco use is increasing diets are rapidly changing physical activity reduces alcohol use increases obesity, diabetes, hypertension Demographic : population is ageing. Globalization : increasing global influences
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THE GLOBAL NCD REALITY

Non-communicable diseases contribute 60 % of deaths and 43 % of the global burden of disease. Already 79% of these NCDs are occurring in developing countries. By 2020 these deaths will account for 73% deaths and 60% of the disease burden. Half of these deaths are attributable to cardiovascular diseases. There are more CVD deaths in india or china than in all developed countries added together.
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WORLD, DEATHS, BY BROAD CAUSE GROUP, 2001

Total deaths: 56,554,000

58.5%
COMMUNICABLE

Noncommunicable conditions (33.1 million)

DISEASES, MATERNAL
AND PERINATAL CONDITIONS AND

32.5%

9.0%
Injuries (5.1 million)

NUTRITIONAL
DEFICIENCIES (18.4 MILLION)

Source: WHR 2002

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WORLD, DALYs, BY BROAD CAUSE GROUP, 2001

45.9%

Noncommunicable conditions

COMMUNICABLE

42.0%

12.2%

DISEASES, MATERNAL
AND PERINATAL CONDITIONS AND

Injuries

NUTRITIONAL
DEFICIENCIES

Source: WHR 2002

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WORLD, DISTRIBUTION OF CAUSES OF DEATH, 2001

Total deaths: 56,554,000

Other NCDs Respiratory infections Respiratory diseases Neuropsychiatric disorders 3% HIV/AIDS 6% 7% Digestive diseases 4% Perinatal conditions 5% 5% Malignant neoplasms Diarrhoeal diseases 3% 13% Tuberculosis 3% Childhood diseases Diabetes Malaria Maternal conditions 9% Nutritional deficiencies 30% Other CD causes Injuries Cardiovascular diseases
Source: WHR 2002
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Vilius GRABAUSKAS

NCDs ARE TO A GREAT EXTENT PREVENTABLE

Key risk factors: unhealthy diet (salty, fatty and sugary food), physical inactivity, tobacco and alcohol drinking.

The behavioural factors lead to high blood pressure & hypertension, blood glucose intolerance & diabetes, elevated blood cholesterol & hypercholesterol, anaemia, overweight and obesity.
Simple changes in these lifestyles can powerfully prevent chronic diseases and promote health. Some of the changes take place relatively quickly and also in late age.
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Vilius GRABAUSKAS

 Chronic diseases are responsible for more than 24 million deaths a year, or almost half of the global total. The leading causes are circulatory diseases, including heart disease and stroke, cancer and chronic obstructive pulmonary disease. infectious diseases kill about 17 million people a year and afflict hundreds of millions of others, particularly in the developing world. In the industrialized world, infectious diseases are well under control. It is noninfectious diseases - particularly cancer, circulatory diseases, mental disorders including dementia, chronic respiratory conditions and musculoskeletal diseases - that now pose the greatest threat to health in developed countries. These are essentially the diseases that strike later in life and which, as life expectancy increases, will become more prevalent.
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 As life expectancy in developing countries also increases, so the people will become more and more prone to diseases that are more common among older age groups. Outlook for most individuals in the developing world is that if they do manage to survive the killer infections of infancy, childhood and maturity, they will become exposed in later life to non communicable diseases. This situation is known as the "epidemiological transition" - the changing pattern of health in which poor countries inherit the problems of the rich, including not merely illness but also the harmful effects of tobacco, alcohol and drug use, and of accidents, suicide and violence. It is also referred to as the "double burden", because of the continuing weight of endemic infectious diseases.
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Industry
Change from agriculture to industry takes place over a few hundred years. Effect on health is profound, with the decline of infectious disease and the rise on non-communicable disease. Modern rise in population is distinguished from all previous increases by its size, continuity and duration. A major contributor is the decline in death rate -increase in normal longevity -- of modern man.

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Industry
Industrialists Risk factors: Sedentary lifestyle Longer life

Abundant food
Processed food Degraded environment Increase in medical technology
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EPIDEMIOLOGY OF CHRONIC NON COMMUNICABLE DISEASES.

"An impairment of structure or function that necessitates a modification of the patients normal life, and has persisted over an extended period of time".

Chronic diseases have one or more of the following characteristics. Are permanent. Leave residual disability. Are caused by non-reversible pathological alteration. Require special training for rehabilitation. Require long period of care and supervision.
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NON COMMUNICABLE DISEASES INCLUDE:

Cardiovascular,

Renal,

Nervous,

Mental,

Musculo-skeletal

(Arthritis), Chronic non-specific respiratory diseases (Chronic bronchitis, emphysema, asthma), Accidents, senility, blindness, Cancer, Diabetes, Obesity, Chronic results of communicable diseases.

NON COMMUNICABLE DISEASES RISK FACTORS:

1. Cigarette smoking 2. Alcohol abuse 3. Inability to obtain preventive health services for hypertension control, cancer detection, and Diabetes management. 4. Life style changes (dietary patterns, physical activity) 5. Environmental Risk Factors (occupational hazards, air, water pollution, Destructive weapons) 6. Stress factors.
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WHY IT IS DIFFICULT TO CONTROL NON COMMUNICABLE DISEASES.

Absence of a known agent: absence of a known agent makes both
diagnosis and prevention difficult.

Multifactorial Causation: Chronic diseases appear to result from the

cumulative effects of multiple risk factors. Many of the risk factors are yet to be identified and evaluated.

Long Latent Period: This makes difficult to link suspected causes with
outcomes.

Indefinite onset: slow in onset & development, Distinction between diseased

and non-diseased is difficult to establish (diabetes, hypertension).

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PREVENTION OF NON COMMUNICABLE DISEASES:

1. Case finding through screening and Health examinations 2. Application of improved methods of diagnosis, treatment 3. Control of food, water, & air pollution 4. Reducing accidents 5. Changing life style 6. Comprehensive Medical care 7. Political approaches

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What is Cardiovascular Disease?

CVD is the name for the group of disorders of the heart and blood vessels and include: Hypertension (high blood pressure) Coronary heart disease (heart attack) Cerebro-vascular disease (stroke) Peripheral vascular disease Heart failure Rheumatic heart disease Congenital heart disease Cardiomyopathies
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Facts: Heart disease has no geographic, gender or socio-economic boundaries In1999 CVD contributed to a third of global deaths. In 1999, low and middle income countries contributed to 78% of CVD deaths. By 2010 CVD is estimated to be the leading cause of death in developing countries

CORONARY HEART DISEASE (IHD): "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".

CHD may present itself as

Angina pectoris Myocardial infarction Irregularities of the heart Cardiac failure Sudden death
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MEASUREMENT OF DISEASE BURDEN:

Proportional mortality Ratio (Proportion to all deaths) Loss of life expectancy CHD incidence Rate Age specific death Rates Prevalence Rate by cross sectional surveys Case fatality rate Measurement of risk factor level Cigarettes smoking, alcohol serum cholesterol in the community. Medical care.

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EPIDEMIOLOGY:
Epidemics USA Britain 1920 1930

CHD is worldwide in distribution Incubation period 10 years or more

CHD IN PAKISTAN: 12% of all deaths or (100,000) deaths per year

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RISK FACTORS
Non Modifiable
Age

Modifiable
Cigarette smoking

Sex

High blood pressure

Family History

Elevated serum cholesterol

Genetic factors Personality

Diabetes Obesity Sedentary habits Stress

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Newly emerging CVD risk factors in low and middle-income countries. Low birth weight Folate deficiency Certain infections Hypercoagulability Water hardness hypercalcemia

PREVENTION OF CHD:
Population strategy Primordial prevention Prevention in whole populations High Risk strategy Secondary prevention
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HYPERTENSION
(The level of blood pressure at which action is warranted)

"A systolic pressure equal to or greater than 140mm Hg or a diastolic pressure equal to or greater than 95mm Hg".

Classification:
Primary (Essential): when the causes are unknown is the most prevalent form accounting for 90% of all cases. Secondary: When some other disease process is involved in its causation (Kidney disease, tumors of adrenal gland, congenital narrowing of aorta, Toxemia's of pregnancy
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MORTALITY:
Major risk factor for stroke,CHD, Kidney failure.
Death rate per 100,000 population from hypertensive disease Country USA Japan Eng & wales France Total 14.4 11.6 10.4 9.9 Male 12.6 9.5 9.4 7.7 8.3 7 5 3.9 Female 16 13.6 11.3 12.1 10.1 9.6 7.2 5.7

New Zealand 9.2 Scotland Canada Netherland 8.3 6.1 4.8

TRACKING OF BLOOD PRESSURE: Low blood pressure levels

tend to remain low and high levels tend to become higher as individuals grow elder, by this children and adolescents at risk can be identified.
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RISK FACTORS FOR HYPERTENSION

Non-Modifiable Age Genetic factors Family history

Modifiable Obesity Salt intake Saturated fat Alcohol Physical inactivity Tension & stress Oral contraception Noise, vibration, temperature.

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PREVENTION OF HYPERTENSION:
1. Primary Prevention (Population Strategy): Nutrition: Salt intake less than 5 grams/day, Low fat, Avoidance of alcohal, energy intake according to body requirement. Weight Reduction Exercise Behavioral changes (reduction of stress, smoking) Health education & Self care High Risk Strategy (Tracking of blood pressure from

childhood). 2. Secondary Prevention (Screening, treatment)

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HYPERTENSION Rule of Halves:

1 4 3 2 5 6 7 8 9

1. 2. 3. 4. 5. 6. 7.

Whole community Normotensive subjects Hypertensive subjects Un-Diagnosed Hypertension Diagnosed Hypertension Diagnosed but untreated Diagnosed & treated

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