Transcript اطلاعات آماری مربوط به

‫اپیدمیولوژ ی بیماری های قلبی عرو قی‬
‫در ایران و جهان‬
‫دکتر اکبر نیک پژوه‬
‫متخصص طب پیشگیری و پشکی اجتماعی‬
‫مرکز آموزشی‪ ،‬تحقیقاتی و درمانی قلب و عروق شهید رجایی‬
‫‪1392/10/21‬‬
‫اولین مدرسه زمستانی اپیدمیولوژی‬
‫تعریف اپیدمیولوژی‬
‫‪ ‬اپیدمیولوژی عبارت است از مطالعه توزیع و عوامل تعیین کننده حاالت و یا‬
‫پیشامدهای مرتبط با سالمتی در جمعیتهای معین و به کارگیری این مطالعه ب رای‬
‫مبارزه با مشکالت بهداشتی‬
‫تعریف بیماریهای قلبی عروقی‬
‫ عروقی‬- ‫براساس یکی از گزارشهای سازمان بهداشت جهانی بیماری های قلبی‬
: ‫شامل مجموعه اختالالت زیراست‬
•Hypertension (high blood pressure)
• Coronary heart disease (heart attack)
• Cerebrovascular disease (stroke)
• Peripheral vascular disease
• Heart failure
• Rheumatic heart disease
• Congenital heart disease
• Cardiomyopathies
• Deep vein thrombosis and pulmonary embolism
‫پیشگفتار‬
‫‪-‬‬
‫(‬
‫‪17/1‬‬
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‫ ‪)2010‬‬‫‪.‬‬
‫پیشگفتار‬
‫‪2006‬‬
‫‪%71‬‬
‫‪2015‬‬
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‫پیشگفتار‬
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‫‬‫‪2/ 5‬‬
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‫‪%39/4‬‬
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‫‪40‬‬
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‫‪40‬‬
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‫پیشگفتار‬
‫‪700‬‬
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‫‪800‬‬
PARTS OF CARDIOVASCULAR
EPIDEMIOLOGY
 1 ., Descriptive epidemiology:
 = Describing distribution of cardiovascular disease by means
of certain characteristics such as : PERSON (i.e., age, gender,
ethnicity) TIME and PLACE
 2., Analytic epidemiology
 = Analyzing relationships between CVD and risk factors (which
elevate the probability of a disease at population level), risk
model and multicausal developments
 3., Experimental epidemiology/Interventions
 = Strategies of cardiovascular prevention (primordial, primary,
secondary, tertiary; individual and community levels)
DESCRIPTIVE EPIDEMIOLOGY I.
DISTRIBUTION PATTERNS IN THE WORLD
 In the world: CVD deaths account for one third of all deaths
(25-50% depending on the level of economic development)
among which 50%: coronary deaths
 CVD made up 16.7 million of global deaths in 2002, among
which 7 million due to coronary heart disease, 6 million due
to stroke
 Distribution of types of CVD in global deaths :
 Global cardiovascular deaths in 2002: 16.7 million
 among which: coronary heart disease 7.2 million > stroke 6.0
million > 0.9 million hypertensive heart disease > 0.4 million
inflammatory heart disease > 0.3 million rheumatic heart
disease > 1 .9 million other CVD
DESCRIPTIVE EPIDEMIOLOGY II. AGE
 Question: What is the relative amount of CVD in death rates in
dif ferent age groups?
 - Early lesions of blood vessel, atherosclerotic plaques: around
20 years - adult lifestyle patterns usually start in childhood
and youth (smoking, dietary habits, sporting behavior, etc.)
 - Increase in CVD morbidity and mortality: in age -group of 3044 years
PROPORTION OF MORTALITY IN
DIFFERENT AGE-GROUPS (MEN)
PROPORTION OF MORTALITY IN
DIFFERENT AGE-GROUPS (WOMEN)
DESCRIPTIVE EPIDEMIOLOGY III. SEX
 Question: What is the relative amount of CVD in death rates in
women and men?
 - Widespread idea: CVD is often thought to be a disease of
middle-aged men.
 - Cardiovascular mortality (fatal cases) are more common among
men. However, CVD affect nearly as many women as men, albeit
at an older age
 - Women: special case (WHO, 2004)
 a., Higher risk in women than men (smoking, high triglyceride
levels)
 b., Higher prevalence of certain risk factors in women (diabetes
mellitus, depression)
 c., Gender-specific risk factors (risks for women only) (oral
contraceptives, polycystic ovary syndrome)
DESCRIPTIVE EPIDEMIOLOGY IV.
ETHNICIT Y
 Question: What is the relative amount of CVD in death rates in
dif ferent ethnic groups?
 - In the US: increased cardiovascular disease deaths in
African- American and South- Asian populations in comparison
with Whites
 - Increased stroke risk in African-American, some Hispanic
American, Chinese, and Japanese populations
 - Migration: Ni-Hon-San Study: Japanese living in Japan had
the lowest rates of CHD and cholesterol levels, those living in
Hawaii had intermediate rates for both, those living in San
Francisco had the highest rates for both
DESCRIPTIVE EPIDEMIOLOGY VI.
WORLD TRENDS
 Developed countries: decreasing tendencies (e.g, USA: 30%
between 1988-98, Sweden: 42%)
 - improvement of lifestyle factors, for example, a decrease of
smoking and a higher level of health consciousness in many
developed countries
 - better diagnostic and therapeutic procedures
(e.g., bypass surgeries, hypertension screening,
pharmacological treatment of hypertension and
hypercholesterinaemia, access to health care)
 Developing countries: increasing tendencies
 - increasing longevity, urbanization, and western type lifestyle
ANALY TIC EPIDEMIOLOGY II.
CLASSIFICATION OF RISK FACTORS
Estimated 10-Year Rate (%)
Estimated 10-Year CHD Risk in
55-Year-Old Adults According to Levels of
Various Risk Factors Framingham Heart Study
40
35
30
25
20
15
10
5
0
37
27
25
20
Men
Women
13
5
8
5
A
B
C
A
D
B
C
D
Blood Pressure (mm Hg)
120/80 140/90 140/90 140/90
Total Cholesterol (mg/dL)
200
240
240
240
HDL Cholesterol (mg/dL)
50
50
40
40
Diabetes
No
No
Yes
Yes
Cigarettes
No
No
No
Yes
Estimated 10-Year Stroke Risk in 55-Year-Old Adults
According to Levels of Various Risk Factors
Estimated 10-Year Rate (%)
Framingham Heart Study
30
27
25
22.4
19.1
20
14.8
15
8.4
10
5
2.6
6.3
5.4
4
3.5
2
1.1
0
A
B
C
D
Men
A
Systolic BP*
95-105
Diabetes
No
Cigarettes
No
Prior Atrial Fib. No
Prior CVD
No
B
130-148
No
No
No
No
Source: Stroke 1991;22:312-318.
E
F
Women
C
130-148
Yes
No
No
No
D
130-148
Yes
Yes
No
No
E
130-148
Yes
Yes
Yes
No
F
130-148
Yes
Yes
Yes
Yes
*BP in millimeters of mercury (mmHg)
Estimated 10-Year Rate (%)
30
27
25
22.4
Men
20
W omen
19.1
14.8
15
8.4
10
5
2.6
5.4
4
2
1.1
6.3
3.5
0
A
B
A
Systolic BP*
95-105
Diabetes
No
Cigarettes
No
Prior Atrial Fib. No
Prior CVD
No
C
B
130-148
No
No
No
No
D
C
130-148
Yes
No
No
No
D
130-148
Yes
Yes
No
No
E
E
130-148
Yes
Yes
Yes
No
F
F
130-148
Yes
Yes
Yes
Yes
*BP in millimeters of mercury (mmHg)
Estimated 10-year stroke risk in 55-year-old adults
according to levels of various risk factors (FHS).
Source: Wolf et al., Stroke.1991;22:312-318.
Offspring CVD Risk by Parental CVD
Status: Framingham Study
Parental CVD <55 men, <65 Women
Risk Ratio
NONE
MATERNAL
PATERNAL
2.5
2
2.2
1.5
1.7
1.7
1.7
1
1.0
1.0
0.5
0
MEN
WOMEN
Adjusted for: age, total/HDL Chol. ratio, SBP, smoking, diabetes, BMI
Risk of Coronary Heart Disease
by Serum Cholesterol
30-Year Follow-up, The Framingham Study
Age-Adjusted Annual Rate per 1000
Serum
Cholesterol
Age: 35-64*
Wome
Men
n
Age: 65-94
Men+
Women*
84-204
8
4
22
11
205-234
13
5
24
15
235-264
14
4
26
17
265-294
15
7
23
17
295-1124
26
10
38
32
*Trends Significant at P.001. +P.07.
Correlation Between Serum
Cholesterol and CVD Mortality
6-Year CVD Death Rate Per 1000
30
Multiple Risk Factor Intervention Trial (MRFIT)
N=325,346
Untreated Patients
25
55-57 years
20
50-54 years
15
45-49 years
10
40-44 years
35-39 years
5
0
Q1
(<182)
Q2
(182-202)
Q3
(203-220)
Q4
(221-244)
Q5
(>244)
Serum Cholesterol Quintile (mg/dL)
Q = serum cholesterol quintile. Kannel WB et al. Am Heart
J. 1986;112:825-836.
_______________________________________________________________________________
Lifetime Risk of CHD Increases
with Serum Cholesterol
___________________________________________________________________________
60
Cholesterol
50
<200 mg
200-239 mg
>240 mg
Percent
40
57
30
44
20
33
34
29
10
19
0
Men
Women
Framingham Study: Subjects age 40 years
DM Lloyd-Jones et al Arch Intern Med 2003; 1966-1972
Percent of Population
45
40
35
30
25
20
15
10
5
0
39.0
32.0 32.0
Total Population
32.0
34.0
NH Whites
Men
32.0 30.0
31.0
NH Blacks
Mexican
Americans
Women
Age-adjusted prevalence of Adults age 20 and older with LDL
cholesterol of 130 mg/dL or higher, by race/ethnicity and sex
(NHANES: 2003-2004). Source: NCHS and NHLBI. NH – non-Hispanic.
Percent of Population
30
25
28
26
25
20
16
13
15
10
9
9
7
5
0
Total
NH Whites
Men
NH Blacks
Mexican
Americans
Women
Age-adjusted prevalence of Adults age 20 and older
with HDL cholesterol <40 mg/dL, by race/ethnicity
and sex (NHANES: 2003-2004).
Source: NCHS and NHLBI. NH – non-Hispanic.
Mean Serum Total Cholesterol
208
206
204
206
204
205
204
202
202
202
201
199
200
197
198
196
194
192
NH White
NH Black
1988-94
1999-02
Mexican American
2003-04
Trends in mean total serum cholesterol among
adults age 20 and older, by race/ethnicity, sex and
survey (NHANES : 1988-94, 1999-02 and 2003-04).
Source: NCHS and NHLBI. NH – non-Hispanic.
Mean Total Blood Cholesterol
180
175
171
170
165
165 166
161
163 163
160
155
172
170
166
163 164
174
168
161
156
155
150
145
White Males
Black Males
1976-80
1988-94
White Females
1999-02
Black Females
2003-04
Trends in mean total blood cholesterol among
adolescents ages 12-17 by race, sex, and survey
(NHES: 1966-70; NHANES: 1971-74 and 1988-94).
Source: NCHS and NHLBI.
Percent of Population
83.8
90.0
80.0
70.0
60.0
50.0
40.0
30.0
20.0
10.0
0.0
73.9
69.5
63.6
55.4
49.1
37.5 37.4
23.2
11.2
18.3
6.4
20-34
35-44
45-54
Men
55-64
65-74
75+
Women
Prevalence of high blood pressure in Adults by age
and sex (NHANES: 1999-2004). Source: NCHS and NHLBI.
CHD Risk by Cigarette Smoking.
Filter Vs. Non-filter. Framingham
Study. Men <55 Yrs.
14-yr. Rate/1000
250
Non-Smoker
Reg. Cig. Smoker
Filter Cig. Smoker
210
206 210
200
150
119
112
100
59
50
0
Total CHD
Myocardial
Infarction
Risk Factor Sum and Obesity
Framingham Study
(1971-74) and (1989-93)
Risk Factor Sum
3
2.4
1.8
(1971)
(1989)
Risk factors accumulate with weight gain
1.2
0.6
0
Q1
Q2
Q3
Q4
Q5
Overall
Thin
Obese
Risk variables include bottom quintile for HDL-C and top
quintiles for cholesterol, SBP, triglycerides and glucose
Percent of Population
20
18
16
14
12
10
8
6
4
2
0
18.7
16.3
11.6
11
6.6
6.4
4.3
3.6
6-11
1971-74
12-19
1976-80
1988-94
2001-2004
Trends in prevalence of overweight among U.S.
children and adolescents by age and survey
(NHANES, 1971-74, 1976-80, 1988-94 and 20012004). Source: Health, United States, 2006, unpublished data. NCHS.
ANALY TIC EPIDEMIOLOGY II.
CLASSIFICATION OF RISK FACTORS
 - Systolic blood pressure >140 Hgmm and/or a diastolic blood
pressure > 90 Hgmm
 - Free of clinical symptoms for many years (screening)
 - In most countries, up to 30 percent of adults suf fering,
increasing with age in civilized countries
 - Positive family history
 - Dietary habits (a high intake of salt, processed food, low
levels of water hardness, high thyramine content of food,
alcohol use)
 - Modern lifestyle (increased sympathetic activity,
psychosocial stress, leading position in job)
ANALY TIC EPIDEMIOLOGY IV.
RHEUMATIC FEVER AND RHEUMATIC HEART DISEASE
 Development: Rheumatic fever usually follows an untreated
beta-haemolytic streptococcal throat infection in children
 As a consequence, the heart valves are permanently damaged
which may progress to heart failure
 Today mostly af fects children in developing countries, linked
to poverty, inadequacy of health care access
 Occurrence: 12 million people currently af fected by rheumatic
fever and RHD, two-thirds are children ( 5-15 years), for
example: approx. 1 000 000 in Sub-Saharan Africa, 700 000
in South-Central Asia, 176 000 in China, 150 000 in North
Africa, 40 000 in Eastern Europe (!)
ANALY TIC EPIDEMIOLOGY V.
ABNORMAL BLOOD LIPIDS
 - Se cholesterol: structure and functioning of blood vessels,
atherosclerotic plaques
 - Altering functions of cholesterol fractions (LDL: risk, HDL:
protection)
 - Estrogen: tends to raise HDL-cholesterol and lower LDL cholesterol, protection for women in reproductive age
 - Partially genetic determination of metabolism, partially
dependent of nutrition (egg, meats, dairy products)
ANALY TIC EPIDEMIOLOGY VI.
TOBACCO USE
 - The link between smoking and CVD (mainly CHD) was
identified in 1940
 - Passive smoking: additional risk
 - Women smokers: are at higher risk of CHD and CVD than
male smokers
 - Several mechanisms: damages the endothelium lining,
increases atherosclerotic plaques, raises LDL and lowers HDL,
promotes artery spasms, raises oxigen demand of the heart
muscle
 - Nicotine accelerates the heart rate (HR), and raises blood
pressure
ANALY TIC EPIDEMIOLOGY VII.
PHYSICAL INACTIVIT Y
 - Regular physical activity: protective factor
 - Intensity and duration (150 minutes/week intermediate or
60 minutes/week heavy)
 - Modernization, urbanization, mechanized transport:
sedentary lifestyle (60% of global population)
 - Raises CVD risk and also the development of other risk
factors (glucose metabolism, diabetes mellitus, blood
coagulation, obesity, high blood pressure, worsening lipid
profile)
 - Physical activity: helps reduce stress, anxiety and depression
ANALY TIC EPIDEMIOLOGY VIII.
OBESIT Y, DIABETES MELLITUS, UNHEALTHY DIET
 - Body Mass Index: > 25: overweight, > 30: obesity
 - A modern ”epidemic”: More than 60% of adults in the US are
overweight or obese, in China: 70 million overweight people
 - Elevates the risk of both CVD and diabetes mellitus
 - Diabetes mellitus: damages both peripheral and coronary
blood vessels
 -Unhealthy diet: low fruit and vegetable, fiber content, and
high saturated fat intake, refined sugar
ANALY TIC EPIDEMIOLOGY IX.
PSYCHOLOGICAL AND SOCIAL FACTORS
 - Psychological factors (Type A behavior, hostility)
 - Depression and CVD: bidirectional link
 a., depression may increase the risk of CVD and worsen
recovery process
 b., CVD may induce depression
 - Low socioeconomic status (SES):
 a., in developed countries: less educated and lower SES
groups (accumulation of risk factors)
 b., in developing countries: more educated and higher SES
groups (western lifestyle)
FIGURE 1-1 CHANGING
PAT T E R N O F M O R TA L I T Y,
1 9 9 0 T O 2 0 01 .
 CMPN = communicable,
maternal, perinatal, and
nutritional diseases
 CVD = cardiovascular
disease
 INJ = injur y
 ONC = other
noncommuni cable diseases.
(From Mather s CD, Lopez A ,
Stein D, et al: Deaths and
disease burden by cause:
Global burden of disease
estimates for 2001 by World
Bank Countr y Groups, 2005.
Disease Control Priorities
Working Paper 18
[http://www.dc p 2.or g/f ile/ 33/
wp18.pdf].)