Transcript Slide 1

Decreasing Risk of
Developing Cardiovascular
Disease
Jill Birnbaum, State Advocacy Consultant,
National Center, American Heart Association
A complete version of this update
is available on our Web site,
www.americanheart.org/statistics
Click on “Heart Disease and
Stroke Statistics — 2006 Update”
Risk Factors
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Tobacco
High Blood Pressure
High Cholesterol
Physical Inactivity
Overweight and Obesity
Diabetes
Nutrition
Metabolic Syndrome
Preventing Cardiovascular
Disease Risk
• Primary Prevention
– Individual
– Environmental
• Secondary Prevention
• Heart disease and stroke are disorders
with complex etiologies and multiple risk
factors, so a multifaceted approach to
their prevention is crucial to success.
Policy and Environmental
Change
• We need to create policy and environmental
changes that will support behavior change
and risk factor prevention and control.
• To support behavior change, risk factor
control, and uniform access to high quality
health care, heart disease and stroke
prevention programs must address policy,
environmental, and systems-level changes
in multiple settings.
Preventing Cardiovascular
Disease Risk
• In direct contrast with conventional thinking, 80%
to 90% of patients with coronary heart disease
have at lease one conventional risk factor
• Although research on nontraditional risk factors
and genetic causes of heart disease is important,
clinical medicine, public health policies, and
research efforts must place significant emphasis
on the four conventional risk factors and the
lifestyle behaviors causing them to reduce the
epidemic of coronary heart disease.
Trends in Cardiovascular Risk Factors
in the U.S. Population Aged 20-74
NHES: 1960-62, NHANES:1971-75 to 1999-2000
45
39.2
Percent of Population
40
35
30
36.0
33.6
33.1
28.2
30.8
27.2
29.3
26.3
26.4
25
20
19.0
17.0
14.8 14.9
15
10
5
1.8
3.4 3.5
4.6 5.0
0
High Total Cholesterol
High Blood Pressure
1960-62
1971-75
Source: JAMA 2005. 293: 1868-74.
1976-80
Smoking
1988-94
Diagnosed Diabetes
1999-2000
Tobacco
• Mortality
– From 1997–2001, an estimated 437,902
Americans died each year of smokingrelated illnesses
– 34.7 percent of these deaths were
cardiovascular-related.
– Cigarette smoking results in a two-to-threefold risk of dying from CHD.
– An estimated 35,052 nonsmokers die from
CHD each year as a result of exposure to
environmental tobacco smoke.
Tobacco
• Primary prevention goal
– Complete cessation
– No exposure to secondhand smoke
Tobacco
• Prevention
– Individual
Stop smoking
 Eliminate exposure to secondhand smoke

– Environmental Change:
Increasing the price of cigarettes through
tobacco tax increases
 Establish smokefree workplace laws
 Support tobacco control prevention and
treatment programs

Tobacco
• The impact to CVD in the first year of making all
workplaces smoke free:
– 1540 myocardial infarctions and 360 strokes would be
averted
– Health care consumers would save $48.6 million in
direct medical costs.
• And, by year seven:
– More than 6250 cumulative myocardial infarctions
would have been averted.
– More than 1270 strokes would have been averted.
– Total averted medical costs of $280 million, of which
$132 million (or 61%) are from former passive
smokers.
High Blood Pressure
• Nearly one in three adults has HBP.
• The prevalence of hypertension in
blacks in the United States is among the
highest in the world.
• Listed as a primary or contributing
cause of death in about 277,000 deaths
in 2003.
• The estimated direct and indirect cost
for HBP in 2006 is $63.5 billion.
High Blood Pressure
• Primary prevention goal
– Goal: <140/90 mm Hg; <130/85 mm Hg
if renal insufficiency or heart failure is
present;
– Or <130/80 mm Hg if diabetes is
present.
High Blood Pressure
• Promote healthy lifestyle
modification
– Advocate weight reduction
– Reduction of sodium intake
– Consumption of fruits, vegetables,
and low-fat dairy products
– Moderation of alcohol intake
– Physical activity
High Blood
Cholesterol
A fat-like substance found
in animal tissue and carried
in the blood. Dietary
cholesterol is present only
in foods from animal
sources such as whole
milk dairy products, meat,
fish, poultry, animal fats
and egg yolks.
Build-up (plaque) in
a blood vessel
High Blood Cholesterol
• Prevalence
– About 10 percent of adolescents ages
12–19 have total cholesterol levels
exceeding 200 mg/dL.
– Almost 100 million American adults
have total blood cholesterol above
200 mg/dL.
High Blood Cholesterol
• Prevention
– Eat foods low in saturated fat, trans fat and
cholesterol.
– Lose weight if you need to.
– Exercise for a total of at least 30 minutes on
most or all days of the week.
– Some people may also need to take
medicine, because changing their diet isn't
enough.
High Blood Cholesterol
• Aftermath
– Less than half of persons who qualify for
any kind of lipid-modifying treatment for
CHD risk reduction are receiving it.
– Less than half of even the highest-risk
persons, those who have symptomatic CHD,
are receiving lipid-lowering treatment
– Only about a third of treated patients are
achieving their LDL goal; less than 20
percent of CHD patients are at their LDL
goal.
Physical (In)Activity
Physical Inactivity
• Prevalence
– 31.3 percent of U.S. adults age 18 and older
engage in any regular leisure-time physical
activity (PA).
– The relative risk of CHD associated with
physical inactivity ranges from 1.5 to 2.4, an
increase in risk comparable to that observed
for high blood cholesterol, high blood
pressure or cigarette smoking.
Physical Inactivity
• Goal: At least 30 minutes of
moderate-intensity physical activity
for adults.
• At least 60 minutes a day for
children.
Physical Inactivity
• We cannot tell our citizens to walk and
bike when there is no safe or welcoming
place to pursue these activities that
promote heart health.
• Promoting healthy and walkable
community environments is essential
both for personal health and for the
long-term health of our communities.
Evidence Based Physical
Inactivity Interventions
• Support a comprehensive physical activity
program in school
– School-based physical education (the cornerstone)
 Require 150 minutes per week of physical
education in grades K-6.
 Require 225 minutes per week of physical
education in middle school.
 Require physical education for graduation.
 Do not allow waivers and substitutions for
physical education.
 Develop quality physical education standards at
the state level.
 Create PE Coordinators at the State Level
– Federal – NCLB/ESEA Policy
Evidence Based Physical
Activity Interventions
• Support a comprehensive physical activity program
in school
– Support Physical Activity Before, After, and During
School – Support physical activity that is
incorporated into the school day through elementary
school recess, structured physical activity in
classrooms, physical activity breaks, physical activity
clubs, and special events.
– Promote walk/bike to school programs and the use of
safe, well-maintained and close-to-home sidewalks,
bike paths, trails, and recreation facilities.
Evidence Based Physical
Inactivity Interventions
• Community-wide campaigns,
including point-of-decision prompts
http://www.do-groove.com/
Evidence Based Physical Activity
Interventions
• Creation of or enhanced access to
places for physical activity combined
with informational outreach activities
• Street-scale urban design and land use
policies and practices
• Community-scale urban design and land
use policies and practices
Overweight and Obesity
• Prevalence
– An estimated 9.2 million children and
adolescents ages 6–19 are considered
overweight or obese.
– Over 10 percent of preschool children ages
2–5 are overweight, up from 7 percent in
1994.
– In 2003, an estimated 136,500,000 American
adults were overweight, and 64,000,000 were
obese.
– Since 1993, the prevalence of those who are
obese increased over 61 percent.
Obesity Trends* Among U.S. Adults
BRFSS, 1985
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
No Data
<10%
10%–14%
Obesity Trends* Among U.S. Adults
BRFSS, 1990
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
No Data
<10%
10%–14%
Obesity Trends* Among U.S. Adults
BRFSS, 1995
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
Obesity Trends* Among U.S. Adults
BRFSS, 2000
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
≥20%
Obesity Trends* Among U.S. Adults
BRFSS, 2005
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
25%–29%
≥30%
Obesity
• Impact
– Obesity was associated with
nearly 112,000 excess deaths
– Abdominal obesity is an
independent risk factor for
ischemic stroke in all racial and
ethnic groups
“the first generation where
children will die before their
parents”
International Congress on
Obesity. August 2002
-Actually, 8 million children
and adolescents are
overweight
- Over the last two decades
the rates for overweight
adolescents have tripled.
-Based on current trends 1
in 3 children born in the year
2000 will develop Type II
Diabetes.
-A National Security Issue
Obesity
• Initiate weight-management program
through caloric restriction and increased
caloric expenditure as appropriate.
• Many obese and overweight people may
have difficulty losing weight, but by
losing even as few as 10 pounds, you
can lower your heart disease risk.
The Search for Evidence
Based Obesity Interventions
• School-based interventions
• Worksite interventions
• Healthcare system
interventions
• Community-wide interventions
Diabetes Mellitus
• Prevalence
– In 2003, the prevalence of physiciandiagnosed diabetes was 14,100,000;
the prevalence of undiagnosed
diabetes was 6,000,000.
– Since 1990, the prevalence of those
diagnosed with diabetes increased 61
percent.
Diabetes Mellitus
• Mortality
– At least 65 percent of people with
diabetes mellitus die of some form of
heart or blood vessel disease.
– Heart disease death rates among
adults with diabetes are two-to-four
times higher than the rates for adults
without diabetes.
Diabetes Mellitus
• First step is diet and exercise.
• Second-step therapy is usually oral
hypoglycemic drugs.
• Third-step therapy is insulin.
Nutrition
• The Economic Research Service of the USDA
suggests that the average daily calorie
consumption in the United States increased by
12 percent between 1985 and 2000, or roughly
300 calories.
• Between 1977 and 1996, portion sizes for key
food groups grew markedly in the United
States, not only at fast-food outlets but also in
homes and at conventional restaurants.
Nutrition
• Impact
– Each year over $33 billion in
medical costs and $9 billion in
lost productivity due to heart
disease, cancer, stroke and
diabetes are attributed to diet.
Nutrition
• Consumption of a variety of fruits, vegetables,
grains, low-fat or nonfat dairy products, fish,
legumes, poultry, and lean meats.
• Match energy intake with energy needs and
make appropriate changes to achieve weight
loss when indicated.
• Modify food choices to reduce saturated fats
(<10% of calories), cholesterol (<300 mg/d), and
trans-fatty acids by substituting grains and
unsaturated fatty acids from fish, vegetables,
legumes, and nuts.
• Limit salt intake
• Limit alcohol intake among those who drink.
Evidence Based Nutrition
Interventions
• School-based nutrition programs;
• Food and beverage advertising to
children; and
• Community approaches to increase
fruit & vegetable intake
Metabolic Syndrome
• Metabolic syndrome (MetS) is
characterized by a group of metabolic
risk factors in one person.
• The syndrome is associated with obesity
and insulin resistance.
• Metabolic syndrome is considered a
clustering of metabolic complications of
obesity.
Metabolic Syndrome
• An estimated 1 million 12–19-year-old
adolescents in the United States have MetS, or
4.2 percent overall
• An estimated 47 million U.S. residents have
MetS. The age-adjusted prevalence of MetS for
adults is 23.7 percent.
• People with MetS are about two times more
likely to have prevalent CHD than those without
the syndrome after adjusting for established
risk factors.
Bottom Line
• Primary prevention of CVD risk
factors can help prevent 80 percent
of coronary heart disease and 90
percent of type 2 diabetes
Secondary Prevention of
Cardiovascular Disease
• There is a growing body of evidence confirms
that aggressive comprehensive risk factor
management improves survival, reduces
recurrent events and the need for interventional
procedures, and improves the quality of life
• The secondary prevention patient population
includes those with established coronary and
other atherosclerotic vascular disease,
including peripheral arterial disease,
atherosclerotic aortic disease and carotid
artery disease.
Components of Secondary
Prevention
Cigarette smoking cessation
Blood pressure control
Lipid management to goal
Physical activity
Weight management to goal
Diabetes management to goal
Antiplatelet agents / anticoagulants
Renin angiotensin aldosterone system blockers
Beta blockers
Influenza vaccination
Cigarette Smoking
Recommendations
Goal: Complete Cessation and No
Exposure to Environmental
Tobacco Smoke
•Ask about tobacco use status at every visit.
•Advise every tobacco user to quit.
•Assess the tobacco user’s willingness to quit.
•Assist by counseling and developing a plan for
quitting.
•Arrange follow-up, referral to special programs,
or pharmacotherapy (including nicotine
replacement and bupropion.
•Urge avoidance of exposure to environmental
tobacco smoke at work and home.
Blood Pressure Control
Recommendations
Goal: <140/90 mm Hg or <130/80 if
diabetes or chronic kidney disease
Blood pressure 120/80 mm Hg or greater:
Initiate or maintain lifestyle modification: weight control,
increased physical activity, alcohol moderation, sodium
reduction, and increased consumption of fresh fruits
vegetables and low fat dairy products
Blood pressure 140/90 mm Hg or greater (or 130/80
or greater for chronic kidney disease or diabetes)
As tolerated, add blood pressure medication, treating
initially with beta blockers and/or ACE inhibitors with
addition of other drugs such as thiazides as needed to
achieve goal blood pressure
Lipid Management
Recommendations
For all patients
Start dietary therapy (<7% of total calories as saturated fat and
<200 mg/d cholesterol)
Adding plant stanol/sterols (2 gm/day) and viscous fiber (>10
mg/day) will further lower LDL
Promote daily physical activity and weight management.
Encourage increased consumption of omega-3 fatty acids in fish
or 1 g/day omega-3 fatty acids in capsule form for risk reduction.
Physical Activity Recommendations
Goal: 30 minutes 7 days/week,
minimum 5 days/week
Assess risk with a physical activity history and/or an
exercise test, to guide prescription
Encourage 30 to 60 minutes of moderate intensity
aerobic activity such as brisk walking, on most,
preferably all, days of the week, supplemented by an
increase in daily lifestyle activities
Advise medically supervised programs for high-risk
patients (e.g. recent acute coronary syndrome or
revascularization, HF)
Weight Management Recommendations
Goal: BMI 18.5 to 24.9 kg/m2
Waist Circumference: Men: < 40 inches
Women: < 35 inches
Assess BMI and/or waist circumference on each visit
and consistently encourage weight maintenance/
reduction through an appropriate balance of physical
activity, caloric intake, and formal behavioral programs
when indicated.
If waist circumference (measured at the iliac crest)
>35 inches in women and >40 inches in men initiate
lifestyle changes and consider treatment strategies for
metabolic syndrome as indicated.
The initial goal of weight loss therapy should be to
reduce body weight by approximately 10 percent from
baseline. With success, further weight loss can be
attempted if indicated.
*BMI is calculated as the weight in kilograms divided by the body surface area in meters2.
Overweight state is defined by BMI=25-30 kg/m2. Obesity is defined by a BMI >30 kg/m2.
Diabetes Mellitus Recommendations
Goal: Hb A1c < 7%
Lifestyle and pharmacotherapy to achieve near
normal HbA1C (<7%).
Vigorous modification of other risk factors (e.g.,
physical activity, weight management, blood
pressure control, and cholesterol management as
recommended).
Coordinate diabetic care with patient’s primary
care physician or endocrinologist. I (C)
HbA1c = Glycosylated hemoglobin
Antiplatelet Agents / Anticoagulation
Recommendations
Renin-Angiotensin-Aldosterone
System (RAAS) Blockers
Recommendations
b-blocker Recommendations
Influenza Vaccination
Patients with cardiovascular disease should have
influenza vaccination
The Need to Implement Secondary
Prevention
•
Multiple studies of the use of these recommended therapies in
appropriate patients continue to show that many patients in
whom therapies are indicated are not receiving them in actual
clinical practice.
•
The AHA and ACC urge that in all medical care settings where
these patients are managed that programs to provide
practitioners with useful reminder clues based on the guidelines,
and continuously assess the success achieved in providing
these therapies to the patients who can benefit from them be
implemented.
•
Encourage that the AHA’s Get With the Guidelines and/or ACC’s
Guidelines Applied to Practice Programs be instituted to identify
appropriate patients for therapy
AHA GWTG Program
GWTG is a national initiative of the AHA to improve
guidelines adherence in patients hospitalized with
cardiovascular disease.
GWTG uses collaborative learning sessions,
conference calls, e-mail and staff support to assist
hospital teams improve acute and secondary
prevention care systems.
A web-based Patient Management Tool is used for
point of care data collection and decision support,
on-demand reporting, communication and patient
education.
Secondary Prevention Conclusions
• Evidence confirms that aggressive
comprehensive risk factor management improves
survival, reduces recurrent events and the need
for interventional procedures, and improves the
quality of life for these patients.
• Every effort should be made to ensure that
patients are treated with evidence-based,
guideline recommended, life-prolonging therapies
in the absence of contraindications or intolerance.
Quality and Availability of Care
Policy
• Promote Adherence to Clinical
Guidelines & Treatment Protocols
• Promote Quality and Performance
Indicators
• Promote Access to Health Coverage
• Monitor Pay-for-quality and Nonfinancial Incentives
• Monitor Drug Formulary Policy
• Monitor Health Information Technology
What should we be working
towards in HIT?
AHA HIT Checklist
1
Includes Clinical Decision Support Tool (GWTGs)
2
Committees/Councils and TAPs include chronic care
representation & guidelines developer
Encourage the funding and evaluation of EHR and PHR
studies
3
4
Ensure patient centric language is included
5
Activities at state level should not conflict with federal
activities by the HHS, AHIC or AHRQ.
Encourages interoperability and connectivity
6
What should we be working
towards in HIT? (Cont.)
AHA HIT Checklist
7
8
Additional research on how consumer incentives can be
used to encourage beneficiaries to utilize PHRs
Minimize potential adverse affect of HIPAA and privacy to
clinical research
9
10
Watch for P4P language and refer to P4Q statement
NFI statement (upcoming)
11
Cost effectiveness (misuse, under use, overuse)
Additional Information
Jill Birnbaum
State Advocacy Consultant
[email protected]
952-278-3643
Q
A
Questions?