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Decreasing Risk of Developing Cardiovascular Disease


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Title: Decreasing Risk of Developing Cardiovascular Disease

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Decreasing Risk of Developing Cardiovascular
Jill Birnbaum, State Advocacy Consultant,
National Center, American Heart Association
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Risk Factors
  • 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
  • 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,
NHANES1971-75 to 1999-2000
Source JAMA 2005. 293 1868-74.

  • Mortality
  • From 19972001, an estimated 437,902 Americans
    died each year of smoking-related illnesses
  • 34.7 percent of these deaths were
  • Cigarette smoking results in a two-to-three-fold
    risk of dying from CHD.
  • An estimated 35,052 nonsmokers die from CHD each
    year as a result of exposure to environmental
    tobacco smoke.

  • Primary prevention goal
  • Complete cessation
  • No exposure to secondhand smoke

  • 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

  • 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 lt140/90 mm Hg lt130/85 mm Hg if renal
    insufficiency or heart failure is present
  • Or lt130/80 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 1219 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
  • 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
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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

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

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

Evidence Based Physical Inactivity Interventions
  • Community-wide campaigns, including
    point-of-decision prompts

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 619 are considered overweight or obese.
  • Over 10 percent of preschool children ages 25
    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. AdultsBRFSS, 1985
(BMI 30, or 30 lbs overweight for 5 4
No Data lt10 1014
Obesity Trends Among U.S. AdultsBRFSS, 1990
(BMI 30, or 30 lbs overweight for 5 4
No Data lt10 1014
Obesity Trends Among U.S. AdultsBRFSS, 1995
(BMI 30, or 30 lbs overweight for 5 4
No Data lt10 1014
Obesity Trends Among U.S. AdultsBRFSS, 2000
(BMI 30, or 30 lbs overweight for 5 4
No Data lt10 1014
1519 20
Obesity Trends Among U.S. AdultsBRFSS, 2005
(BMI 30, or 30 lbs overweight for 5 4
No Data lt10 1014
1519 2024 2529
  • Impact
  • Obesity was associated with nearly 112,000 excess
  • Abdominal obesity is an independent risk factor
    for ischemic stroke in all racial and ethnic

  • the first generation where children will die
    before their parents
  • International Congress on Obesity. August 2002
  • Actually, 8 million children and adolescents are
  • 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

  • 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
  • School-based interventions
  • Worksite interventions
  • Healthcare system interventions
  • Community-wide interventions

Diabetes Mellitus
  • Prevalence
  • In 2003, the prevalence of physician-diagnosed
    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
  • Third-step therapy is insulin.

  • 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
  • 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.

  • 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.

  • 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
  • Modify food choices to reduce saturated fats
    (lt10 of calories), cholesterol (lt300 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 1219-year-old adolescents
    in the United States have MetS, or 4.2 percent
  • 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

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 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 users willingness to quit.
  • Assist by counseling and developing a plan for
  • 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 lt140/90 mm Hg or lt130/80 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
  • 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

Lipid Management Recommendations
For all patients
Start dietary therapy (lt7 of total calories as
saturated fat and lt200 mg/d cholesterol) Adding
plant stanol/sterols (2 gm/day) and viscous fiber
(gt10 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 lt 40 inches Women lt 35 inches
  • Assess BMI and/or waist circumference on each
    visit and consistently encourage weight
  • reduction through an appropriate balance of
    physical activity, caloric intake, and formal
    behavioral programs when indicated.
  • If waist circumference (measured at the iliac
    crest) gt35 inches in women and gt40 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 BMI25-30 kg/m2.
Obesity is defined by a BMI gt30 kg/m2.
Diabetes Mellitus Recommendations
Goal Hb A1c lt 7
Lifestyle and pharmacotherapy to achieve near
normal HbA1C (lt7). Vigorous modification of
other risk factors (e.g., physical activity,
weight management, blood pressure control, and
cholesterol management as recommended).
Coordinate diabetic care with patients primary
care physician or endocrinologist. I (C)
HbA1c Glycosylated hemoglobin
  • Antiplatelet Agents / Anticoagulation

  • 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 AHAs Get With the Guidelines
    and/or ACCs 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

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 Non-financial
  • Monitor Drug Formulary Policy
  • Monitor Health Information Technology

What should we be working towards in HIT?
What should we be working towards in HIT? (Cont.)
Additional Information
  • Jill Birnbaum
  • State Advocacy Consultant
  • 952-278-3643


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