Group Members: Aamod Dhoj Shrestha

Suriya Kumar Lysette

Save Our Heart

INTRODUCTION:
Cardiovascular disease (CVD) comprises of a group of diseases of the heart and the vascular system.

The major conditions are:

Coronary Heart Disease (CHD): IHD/ MI/ Angina/ Heart Attack disease of the blood vessels supplying the heart muscle

Cerebrovascular Disease: Stroke

- disease of the blood vessels supplying the brain

Peripheral Arterial Disease

- disease of blood vessels supplying the arms and legs - damage to the heart muscle and heart valves from rheumatic fever, caused by streptococcal bacteria - malformations of heart structure existing at birth blood clots in the leg veins, which can dislodge and move to the heart and lungs.

Rheumatic Heart Disease

Congenital heart disease Deep Vein Thrombosis and Pulmonary Embolism

Problem Statement
In todays world, most deaths are attributable to non-

communicable diseases (35 million) and just over half of these (17 million) are as a result of CVD; more than one-third of these deaths occur in middle-aged adults. In developed countries, heart diseases and stroke are the first and second leading cause of death for adult men and women. These facts are familiar and hardly surprising, however, surprisingly in some of the developing countries, CVD have also become the first and second leading causes responsible for one-third of all deaths. CVD diseases are

responsible for about 25 per cent of the DALYs lost due to NCD diseases in SEAR countries.

Table:1
Mortality and burden of diseases in DALYs due to CVD, global estimates for 2004 Region
Europe Western Pacific SEAR

Deaths

DALYs last (000)

4,767
4,094
3,875

34,760

31,759

42,061
15,217
14,243

Americas
Africa

1,969
1,175

East Mediterranean

1,163
17,073

13,095
151,377

World

In India, an estimated 1.5 million people die of CVD every year. The burden of common CVD are, about 2.4 million IHD, 0.93 million stroke cases every year. Compared with all other countries, India suffers a highest loss in potentially productive years of life, due to deaths from CVD in people aged 35-64 years (9.2 million lost in 2000). The prevalence of CVD is reported 2-3 times higher in the urban population as compared to the rural population.

Coronary Heart Disease (CHD)

CHD - disease of the blood vessel supplying the heart muscle.
Burden of disease:

An estimated 17.1 million people died from CVDs in 2004. Of these

deaths, an estimated 7.2 million were due to CHD.

Table: 2 Mortality and morbidity due to CHD global estimates for 2004 Region Deaths DALYs last Africa SEAR Americas East Mediterranean Europe Western Pacific World 346 2,011 925 579 2,296 1,029 7,198 3513 21,583 6,523 6,154 16,826 7,882 62,587

CHD cont.
Table: 3 Indices of burden of disease for CHD, India 2004.
Indices Prevalence rate/ 1000
Death rate/ 1000 DALY per 100,000

Urban 64.37
0.8 2703.4

Rural 25.27
0.4 986.2

Risk Factors:
The aetiology of CHD is multifactorial. Some of the risk factors are

modifiable, others immutable. Presence of anyone of the risk factors places an individual in a high-risk category for developing CHD. The greater the number of risk factors present, the more likely one is to develop CHD. Table:4 Risk factor for CHD
Not modifiable Age Sex Family history Genetic factors Personality (?) Modifiable Cigarette smoking High blood pressure Elevated serum cholesterol Diabetes Obesity Sedentary habits Stress

Prevention CHD
Strategies recommended by the WHO expert committee:
a.

Population Strategy (i) prevention in whole population CHD is primarily a mass disease. This approach is based on the principle that small change in risk factor levels in total population can achieve the biggest reduction in mortality. The population strategy centres round the following key areas; dietary changes, smoking , blood pressure, physical activity. (ii) primordial prevention in whole population It involves preventing the emergence and spread of CHD risk factors and life styles that have not yet appeared or become endemic. This applies particular to developing countries to preserve their traditional eating patterns and lifestyles associated with low levels of CHD risk factors. The aim is to change the community as a whole, not the individual subjects living in it.

b.

High risk strategy: (i) Identifying risk Interventions can only be started by identifying the high risk people by means of sample test such as blood pressure and serum cholesterol measurement, those who smoke, strong family history of CHD, diabetes and obesity and young women using oral contraceptives. (ii) Specific Advice Having identified those at high risk, the next step will be to bring them under preventive care and motivate them to take positive action against all the identified risk factors. Secondary prevention: The aim of secondary prevention is to prevent the occurrence and progression of CHD. Secondary prevention is rapidly expanding field with much research in progress (e.g., drug trials, coronary surgery, use of pace makers). The primary and secondary prevention studies promise at present to be the main contribution of epidemiology to the conquest of chronic diseases.

c.

Hypertension:
Hypertension is a chronic condition of concern due to its

role in the causation of CHD, stroke and vascular complications. It is one of the major risk factors for cardiovascular mortality, which accounts for 20-50 per cent of all deaths.
Table:1 Classification of blood pressure measurements Category Normal High normal Systolic blood pressure (mm of Hg) < 130 130 - 139 Diastolic blood pressure (mm of Hg) < 85 85 90

Hypertension Stage 1 ( Mild)

Stage 2 ( Moderate) Stage3 ( Severe)

140 - 159
160 179 > 180

90 99
100 - 109 > 110

Risk factors for hypertension

It may be classified as: 1. Non- modifiable risk factor Age, Sex, Genetic factors, Ethnicity. 2. Modifiable risk factors: Obesity, Salt intake, Saturated fat, Dietary fibre, Alcohol, Heart rate, Physical Activity, Environmental Stress, Socio-economic status, Other factors.

Prevention of hypertension
Primary prevention Primary prevention has been defined as all measures to reduce the incidence of disease in a population by reducing the risk of onset. The earlier the prevention starts the more likely is to be effective. (a) Population strategy Nutrition, Weight reduction, Exercise promotion, Behavioral changes, Health education, Self care. (b) High risk strategy The aim of this approach is to prevent the attainment of levels of blood pressure at which the institution of treatment would be considered. 2. Secondary prevention The goal of secondary prevention is to detect and control high blood pressure in affected individuals. The control measure comprise: (i) Early case detection (ii) Treatment (iii) Patient compliance
1.

Stroke
The term stroke is applied to acute severe manifestations of

cerebrovascular disease. It causes both physical and mental crippling. WHO defined stroke as rapidly developed clinical signs of focal disturbance of cerebral function; lasting more than 24 hours or leading to death, with no apparent cause other than vascular origin. The 24 hours threshold in the definition excludes transient ischaemic attacks (TIA).The disturbance of cerebral function is caused by three morphological abnormalities, i.e. , stenosis, occlusion an or rupture of the arteries.

Problem

An estimated 5.7 million deaths were due to stroke in 2004.

Risk factors
Epidemiological studies have indicated that stroke does not

occur at random, and there are factors (risk factors) which precede stroke by several years. These are: Hypertension, other factors such as cardiac abnormalities (LVH, Cardiac dilation), diabetes, elevated blood lipids, obesity etc. The importance of these factors is not clearly defined. Host factors (i) Age: Stroke can occur at any age. (ii) Sex: The incidence rates are higher in males than females at all ages (iii) Personal history: The WHO study showed that nearly threequarters of all registered stroke patients had associated disease, mostly in CV system or of diabetes. Stroke control Program The aim of stroke control program is to apply at community level effective measures for the prevention of stroke. The first priority goes to arterial hypertension which is a major cause of stroke.

Rheumatic Heart Disease (RHD)

Rheumatic heart disease is caused by damage to the heart valves and heart muscle from the inflammation and scarring caused by rheumatic fever. Rheumatic fever is caused by streptococcal bacteria, which usually begins as a sore throat or tonsillitis in children.
Problem

Rheumatic fever mostly affects children in developing countries, especially where poverty is widespread. Globally, almost 2% of deaths from cardiovascular diseases is related to rheumatic heart disease. In India RHD is prevalent in the range of 5- 7 per thousand in 5- 15 years age group and there are about 1 million RHD cases in India which constitutes 20-30 per cent of hospital admissions due to CVD.

Agent Factors
( Streptococcus pharyngitis )

RHD
Host Factors (I) Age: 5-15 years (II) Sex: effects both male & female equally (III) Immunity: toxic immunological hypothesis. Environmental Factors Socio-economic status: social disease linked to poverty, overcrowding, inadequate health services & health professionals, low level of awareness of the disease in the community.

Prevention
Two preventives approaches are possible:

a. Primary prevention b. Secondary prevention

c. Non-medical measures
d. Evaluation

The goals are to prevent CHD, CeVD and PVD events by lowering cardiovascular risk.

The recommendations assist people to:

Quit tobacco use,

or reduce the amount smoked, or not just start the habit

Physical activity Reduce BMI, waist hip ratio/waist circumference

Maintain optimum BP Make healthy food choices

Lower blood cholesterol and low density lipoprotein

cholesterol(LDLcholesterol)

Control hyperglycemia
Take anti platelet therapy when necessary.

PRIMORDIAL PREVENTION
Prevent the emergence and spread of CVD risk factors and lifestyles that have not yet appeared or become endemic. It is a multifactorial approach that aims to control or modify as many risk factors as possible.

Primary prevention
1. DIETARY CHANGES

-Reduction of fat intake to 20-30 % of total energy intake. -Saturated fat comsumption <10% of total energy intake. -Dietary cholesterol below 100mg per 100 Kcal per day. -Increase in complex carbohydrate consumption Vegetables,fruits,whole grains and legumes -Avoidance of alcohol consumption; reduction of salt intake to 5g daily or less.
2. SMOKING

Promotion of a smoke-free society: -Effective information and education activities -Legislative restrictions -Fiscal measures -Smoking cessation programmes
3. BLOOD PRESSURE

Reduce mean population blood pressure levels: -Reduce salt intake and avoidance of a high alcohol intake -Regular physical activity -Weight control
4. PHYSICAL ACTIVITY

-Regular physical activity

SECONDARY PREVENTION
It is the continuation of the primary prevention. The aim is to prevent the recurrence and progression of CVDs. A. Lifestyle advice B. Pharmacotherapy -Antihypertensive drugs -Lipid lowering drugs -Hypoglycemic drugs -Antiplatelet drugs -ACE Inhibitors -Beta blockers -Anticoagulants C. Surgery -Coronary revascularisation -Carotid endaterectomy or stenting

References:
K. Park,
A text book of Preventive and Social Medicine.

Thank You