Transcript New Trends in Heart Disease

New Trends in Heart Disease
Prof Chu-Pak Lau
Cardiology Division
University of Hong Kong
Queen Mary Hospital
Public Health Conference
6 March 2004
1
Global Burden of CVS disease
Bonow RO et al Circ 2002; 106:1602-1605

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CVS death toll :
14.7M in 1990 to 17M 1999
Main burden due to CAD, is the leading cause of death
worldwide (30%). CVA second leading cause
WHO : 1 Billion people overweight
18M children <5 are overweight
60% of the world population is physically inactive
DM : 150M people, will double in 2025
Tobacco consumption still increasing
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 Coronary Artery Disease
Heart Failure
Atrial Fibrillation
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CVS Death per 100,00 population AHA
Heart & Stroke Statistics 1999
Men
Women
Argentina
Russia
Scotland
Germany
US
New Zealand
Australia
Hong Kong
China (Urban)
China (rural)
Japan
0
200
400
600
800
0
100
200
300
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CAD mortality in Asian-Pacific
(Men /100,000)
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CAD mortality in Asian-Pacific
(Women /100,000)
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Sino-MONICA Project.
Circulation 2001; 103:462-468(1)
7 Year project (1987-1993)
•WHO project
•Collaboration with BIHLBD
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Sino-MONICA Project.
Circulation 2001; 103:462-468(2)
1. Incidence and mortality of CVS disease is low but
those of CVA were high
2. Great disparity in incidence
CVS : 108.7/100,000 to 3.3/100,000 for men
CVA : 553.3/100,000 to 33/100,000
3. Geographical difference :
North > South
e.g. Beijing 70.3 vs Guangdong 59.7/100,000
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Leading Cause of Death in HK (2000)
8000
7000
Male
6943
Female
6000
5000
4279
4000
2846
3000
2691
1744
2000
1809
1000
0
Cancer
Heart disease
CVA
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Leading Causes of Death in US and
HK (Female) Year 2000
Per
100,000
population
160
145.3
US
HK
140
120
100
80
60
57.8
44.3
51.6
40
42.8
29.5
26.6
11.3
20
0
CAD
CVA
Long Cancer
Breast Cancer
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Special Features of Heart Disease
of Women
1.
2.
3.
4.
5.
6.
7.
Older
Delayed presentation
Higher mortality rate
Triple vessel disease and smaller vessel size
Higher CABG risk
Suboptimal response to PTCA
Despite a lower CAD risk, HK women have
mortality from strokes comparable to the US
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Modifiable Risk Factors
Hypertension
Hypercholesterolemia
Diabetes mellitus
Homocysteine
C-Reactive Protein
Exercise
Obesity
Cigarette smoking
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BP, Cholesterol and Stroke in Eastern Asia Eastern Stroke and
Coronary Heart Disease Collaborative Research Group Lancet
1998; 352; 1801-1807
Serum Cholesterol in Urban Cities of
Asia
Men
Mg/dl
250
221 226
209 211
200
Women
185 188
211 210
179
192 194
189
All
206 213
223 218
213
235 237
219
150
100
50
0
il
Tha
re
and
o
gap
Sin
ia
s
l)
s
an)
ines
lipp
Phi
ays
M al
sia
re
(nra
one
Ind
ia
Ind
HK
na
Chi
o
gap
Sin
Urb
ines
lipp
Phi
na (
Chi
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Global Prevalence of Diabetes
1997
2010
124 million (2.1%)
221 million
53% in Asia
61% in Asia
(Amas, McCarthy & Zimmet; Diabetic Med, 1997)
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Prevalence of Diabetes and IGT China
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Obesity
Prevalence in the US in American white (1999-2000)
Adults
Male
Female
27.3%
30.1%
Obesity : BMI > 30
Children
6-11 years
Male
Female
12.0%
11.6%
Adolescents
12-19 years
Male
Female
12.8%
12.4%
CDC 1999-2000
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Mortality from CAD in HK
(Dept of Health Annual Report 1997-2001)
No. of Pts
4000
AMI
(1)
Other CAD
3500
3000
2500
1580
1188
1396
1229
1854
1785
1904
1991
1992
1993
1421
1426
1408
1440
1434
1406
1609
2000
1500
1000
1842
1818
1891
1994
1995
1996
1825
1898
1997
1998
1898
2025
1558
500
0
1999
2000
2001
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Mortality from CAD in HK (<45yrs)
(Dept of Health Annual Report 1997-2001) (2)
% of Heath Disease <45 years
%
12
CAD
Other CAD
1.41
10
8
6
9.95
4
0.9
2
0.89
2.9
2.62
1999
2000
0
2001
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The Role of Platelets in Inflammation
and Plaque Stability
Activated platelets
Inflammatory modulators
CD40L
Platelet-derived growth factor
Platelet factor 4
RANTES
Plaque rupture
& thrombosis
Thrombospondin
Transforming growth factor-
Nitric Oxide
Libby P. Circulation 2001:103:1718-1720
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Novel Risk Factors as Predictors of
Peripheral Arterial Disease
Lipoprotein(a)
Homocysteine
VCAM-1
Fibrinogen
LDL-C
ICAM-1
hs-CRP
TC:HDL-C
CRP + TC: HDL-C
0
1.0
2.0
4.0
6.0
Relative Risk of Incident Peripheral Arterial Disease
(Adjusted for age, smoking, DM, HTN, family history, exercise level, and BMI)
Ridker et al. JAMA 2001;285:2481-2485
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AHA/CDC Recommendations for
Clinical and Public Health Practice
Clinical Practice
• Measurement of hs-CRP is an independent marker of risk and, in
those judged at intermediate risk by global risk assessment
(10%-20% CHD/10 yr) may help direct further evaluation &
therapy in primary prevention of CHD. The benefits of such
therapy based on this strategy remain uncertain. (Class IIa, Level
of Evidence B)
• Measurement of hs-CRP may be used at discretion of the
physician as part of global risk assessment in adults without
known CVD. The benefits of such therapy based on this strategy
remain uncertain. (Class IIb, Level of Evidence C)
AHA/CDC Statement. Circulation 2003; 107:499–511
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Hong Kong
Cardiovascular Risk Factor
Prevalence Study-2 (CRISPS2)
Bernard Cheung
Department of Medicine
University of Hong Kong
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HT prevalence
Prevalence %
60
50
CRISPS1
40
CRISPS2
30
20
10
Age groups
0
<35
35-44
45-54
55-64
65-74
>74
Percentage prevalence of diabetes
Age
1995-6
2001-2
<35
35-44 45-54 55-64 65-74
>74
Male
2.0
5.8
7.5
18.6
21.7
--
Female
1.4
3.2
10.9
21.2
29.3
--
Male
2.8
9.2
8.8
23.0
34.5
30.0
Female
3.4
4.8
6.0
29.8
33.3
43.5
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Weight
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Body weight increased by 0.54±0.14 kg
(p<0.001)
There was no significant change in body
mass index (BMI)
Waist circumference increased from
78.3±0.3 to 80.5±0.3 cm (p<0.001)
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Prevalence of overweight and obesity
in the study population
BMI
<25
25-30
>30
Female
N=540
69.3%
26.1%
4.6%
Male
N=506
61.2%
34.5%
4.4%
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Overweight, diabetes and hypertension
•BMI25 is associated with
diabetes (OR 3.1 [2.0-4.7]) and
hypertension (OR 3.5 [2.5-5.0])
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Conclusions
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In the CRIPS2 cohort, hypertension
(27%), diabetes (15%),
hypercholesterolaemia (46%) and
overweight (35%) are common
As these risk factors can be modified
by diet and lifestyle, the prevention of
cardiovascular disease requires a
community approach
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Coronary Artery Disease
 Heart Failure
Atrial Fibrillation
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Heart Failure : How Big is the
Problem Really?

4,790,000 Americans have heart failure
• Based on extrapolation of NHANES data

550,000 new cases each year
• Based on extrapolation of 44-year Framingham data
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HF contributed to 287,200 deaths in 1999
• Primary cause in 54,913
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HF deaths have increased by 145% in 20years
• Age-adjusted rates have not changed
• Mortality rates may be declining

Hospital discharges increased from 377,000 to
962,000 between 1979 and 1999
• Age adjusted rates and length of stay are declining
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65+
45-64
A New Epidemiology of Ventricular
Dysfunction
The Old Epidemiology of CHF :
•
Included only symptomatic LV failure
•
Often excluded persons > 75 years old
•
Did not characterize ventricular function
The New Epidemiology of Ventricular Dysfunction :
•
Includes assessment of ventricular structure and systolic /
diastolic function
•
No age limits
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Community Echo Survey of Systolic and
Diastolic LV Dysfunction
Redfield MM et al, JAMA 2003; 289: 194-202
Pts & Methods
1997-2000 : 2042 subjects of
Olmsted County were screened
with echo and Doppler, and
followed for ~5yrs
Results
CHF : 2.2%
Systolic Dysfunction : 6%
EF > 50% : 44%
Diastolic Dysfu : Mild 20.6%
Mod 6.6%
Severe 0.7%
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Pharmacotherapy

ACEI

Angiotensin II blockers

Betablockers

Aldosterone antagonist

Newer agents
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Declining Mortality in Heart Failure Trial
Severe
Mild-Mod
20
40
15
20
10
5
0
0
V-HeFT I SOLVD Pla
Pla
SOLVD
Ace
MERIT BB Val-HeFT
RALES
Aldo
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Prevalence of Heart Failure with
Preserved EF
51%
43%
78%
53%
46%
80%
EF>
45%
60%
40%
EF>
50%
EF>
45%
EF>
40%
EF>
50%
EF>
50%
N=73
N=137
N=269
N=338
N=782
Framingham
Olmstead
CHS
CA HMO
CA Medicare
20%
0%
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Main Problems of Electrical Alterations
1. PR prolongation (improper LV filling)
2. Interventricular asynchrony (RV-LV asynchrony)
3. Intraventricular asynchrony (regional LV
asynchrony)
Results in :
1.  Stroke volume
2.  Contractility
3. MR
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Before
After
CRT or Reverse Remodelling ?
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CRT Trials
6m HW (m)
Control
400
386*
Echo (LVED in mm)
Trial
Control
Control
71
70
68*
73
69*
30*
71
69
28*
26*
25
25
318
30*
30
67
345
320
Trial
35
74
352*
342
Trial
80
384*
365*
350
LVEF (%)
22
60
24
23
20
300
50
15
250
40
PATHCHF
MUSTIC MIRACLE CONTAK
CD
*Significant Improvement
10
PATHCHF
MUSTIC
MIRACLE CONTAK
CD
PATHCHF
MUSTIC
MIRACLE CONTAK
CD
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COMPANION : Death or HF Hospitalization
(% of composite Endpoints)
Bristow MR ACC 2003
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Coronary Artery Disease
Heart Failure
 Atrial Fibrillation
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AF : Incidence/resource implication
In USA :
2 million; 160,000 new cases/yr
3-5% population >60yr
1.5 million primary reasons for
consultation
1.4 million hospital discharges
130,000 A&E visits
6.6 billion US$ Medicare
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Prevalence of AF in Elderly
Ryder & Benjamin AJC 1999
(%)
7
6.5
6
5
4.8
5.1
4
3
2
1.3
1.3
1
0
Countries USA Netherlands UK
Age (yrs) (70-80)
(70-80)
(70-80)
0.1
Hong Kong Japan
(60-94)
(>40)
Himalaya
(>15)
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AF and Mortality : Framingham Heart Study
Benjamin et al Circulation 1998; 98:946-952
(%)
Men : 1yr Cx
5
No AF
Methods :
5209 subjects, age 55-94, follow-up for
40yrs. AF documented by biennial
ECG
AF
4
Result :
AF increases mortality by 50% in men
and 100% women
3
2
Conclusion :
Maintenance of sinus rhythm may
decrease mortality
1
0
CHD
CVA
Total
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Prevalence of AF in Heart Failure Trials
Study
NYHC
Prevalence,
%
SOLVD
Prevention
SOLVD Treatment
V-HeFT
CHF-STAT
DIAMOND-CHF
GESICA
CONSENSUS
I
II-IV
II-III
II-III
III-IV
III-IV
IV
4.2
10.1
14.4
15.4
25.8
28.9
49.8
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AT/AF Affect Survival ?
Mortality (%)
AF
No AF
60
50
48%
43%
40
34%
32%
29%
30
34%
30%
23%
21.8%
20
10
3.2%
0
MiddleKauff1
1.
2.
3.
4.
5.
Framingham2
SOLVD3
DIG4
VA-CHF5
Middlekauff HR et al Circulation 1991; 84:40-48
Benjamin EJ et al Circulation 1998; 98:946-952
Dries DL et al JACC 1998; 32 : 695-703
Mathew J et al Chest 2000; 118: 914-922
Carlson PE et al Circulation 1993; 87 (supple) : VI 102-110
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Emergence of New Epidemics of
CVS Disease
Two new epidemics of cardiovascular
disease are emerging : heart failure and
atrial fibrillation
E. Braunwald
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Therapeutic Strategies in AF
Rate Control
Necessary for all therapy
Minimal S/E
Symptomatic benefit
 EF
? ET
vs
Maintain SR
Theoretically sound
After restoring SR
 EF
 ET
 atrial function
?  stroke
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AFFIRM Study :
N Engl J Med Dec 2002; 347 : 1825
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Strategies for AF Management in CHF
•
Drug
•
Ablate & pace
•
Pulmonary vein ablation
•
Atrial defibrillators
•
Main cause of AF is HT
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Global Approach to Reduce CVS/CVA
Death





International cooperation
Research and Education
Targeted primary prevention strategies
e.g. tobacco use, hypertension control,
affordable clinical algorithm
Advocacy e.g. World Heart Day
Availability of cost-effective meds
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The Hong Kong AMI Registry 1995-1996 Woo
KS et al for the HK-AMI Task Force
Background :
A territory wide survey of all cases of AMI
admitted into hospital. Initiated by the HK
College of Cardiology
Subject and Methods :
A total of 3334 AMI (diagnosis by symptom,
ECG and enzyme) were prospectively entered
into a centralized data base, and uniformity
and accuracy of data were audited by a
research coordinator. In-hospital mortality
complication were examined 96.2% were
ethnically Chinese
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Demographics of AMI in HK (95-96)
Sex
(%)
70
Age
67.3%
40
60
31.3% 31.9%
30
50
40
32.7%
30
20
14.8%
20
10
10
32.7%
1.4%
0
9
>7
79
70
69
60
59
50
49
Female
72.9 yrs
40
Male
64.8 yrs
0
<4
0
Sex
Age
14.8%
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AMI Incidence & Mortality in US (1975-1995)
Goldberg RJ Et al Circulation 1999; 33: 1533-1539
Mortality (%)
Mortality
Incidence
Incidence /100,000
30
300
HK
23.8
25
HK
22.4
20
250
200
15
150
10
100
5
50
0
0
75-78
81-84
86-88
90-91
93-95
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