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Cardiovascular Disease Preventive Medicine 2005

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Cardiovascular Disease; Preventive Medicine 2005. David R. Rudy, M.D., M.P.H. ... When neglected, presents as hypertensive heart disease (LVH, pulmonary edema), CAD ... – PowerPoint PPT presentation

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Title: Cardiovascular Disease Preventive Medicine 2005


1
Cardiovascular Disease Preventive Medicine 2005
  • David R. Rudy, M.D., M.P.H.
  • Professor and Chairman
  • Family and Preventive Medicine
  • Chicago Medical School, RUMS

2
Atherosclerotic Vascular Disease
  • Risk Factors,
  • Screening to Prevent

3
Atherosclerotic Disease
  • Coronary artery disease (CAD)
  • Cerebrovascular disease CVD)
  • Peripheral vascular disease (PVD)
  • Reno-vascular dis. and renal failure (CRF) gtgt
    hypertension

4
Coronary Artery Disease (CAD)
  • 1.5 million myocardial infarctions (MI)/year/US
    700,142 deaths from CAD
  • 15 case fatality w/ acute MI 30 case fatality
    w/ acute MIs as first indication of CAD
  • Riskshigh BP, dyslipidemia, physical inactivity,
    diabetes mellitus, age. (obesity)
  • Smoking
  • Genetics

5
Screening versus Prevention (1)
  • Screening for CAD in general population is
    impractical (e.g. screening EKGs, stress testing,
    coronary angiograms)
  • Resting EKGs not sensitive enough EKG stress
    testing not sensitive enough in high risk
    populations
  • Thallium stress/EKG too sensitive in low risk
    populations
  • Coronary angiograms too risky and too expensive
    for screening

6
Screening versus Prevention (2)
  • Primary (and secondary) prevention of CAD through
    control of controllable risk factors
  • Screening is for risk factors imperfect but cost
    effective and tolerable

7
Risk factors for CAD (and other athero- sclerotic
vascular dis
  • Controllable Hypertension, diabetes,
    dyslipidemia, smoking, C-reactive protein,
    (emotional stress)
  • Uncontrollable inheritance

8
Risk factors tend toward clusters hypertension,
diabetes, dyslipidemia
  • Metabolic syndrome X and insulin resistance
    (strong assoc. w/ obesity strongly familial but
    remediable)

9
Metabolic Syndrome X
  • Insulin resistance, hyperinsulinemia, incipient
    diabetes type II
  • Hypertension
  • Dyslipidemia ? TC, LDLC, TGs, ? HDLC

10
Criteria for metabolic syndrome X any 3/5
  • 1. Abdominal obesity waist measurement gt 102 cm
    (40 in.) in men, 88 (35 in.)cm in women.
  • 2. Hypertrigyceridemia ? 150 mg/dL (?1.69
    mmol/L)
  • 3. Low HDL cholesterol ? 40 mg/dL (1.04 mmol/L)
    lt 50 mg/dL for women
  • 4. High blood pressure ?130/85 mm Hg or
    hypertension under treatment
  • 5. High fasting blood glucose ? 110 mg/dL (6.1
    mmol/L) or taking Rx for D/M
    Executive Summary of the Third Report of the NCEP
    etc. (ATP III). JAMA 2001 2852486-2496

11
Relationship between diabetes and hypertension
  • Diabetics have a 50 prevalence of hypertension
    (compare to 15-20 of US population) even when
    corrected for weight
  • Hypertensives have prevalence of glucose
    intolerance (abn BS patterns) 15-18 (compare
    to 5-6 of adult US pop. w D/M) - a significantly
    larger percentage is assumed to have insulin
    resistance w/o glucose intolerance

12
Obesity, diabetes, hypertension and dyslipidemia
  • 80-90 of type II diabetics are obese
  • Prevalence of obesity and of diabetes type II
    have risen in parallel since 1980.
  • 33 increase in prevalence of D/M between 1990
    and 1998

13
CAD electrocardiogram resting EKG as screen
  • ST depression, T wave inversion, Q waves, LVH may
    diagnose CAD.
  • However, seldom CAD presents w/o symptoms so EKG
    poor screen.
  • E.g.in CAD occurs in 1-4 of middle aged men w/o
    sympts
  • of those, 3-15 developed symptomatic CAD over
    5-15 years.

14
CAD electrocardiogram resting EKG as screen (2)
  • 1-4 of middle aged men have CAD w/o symptoms
    (angiographic proof)
  • of those, 3-15 developed symptomatic CAD over
    5-15 years
  • Thus, at most, prevalence of CAD in asymptomatic
    males 0.6 of middle aged men

15
CAD screening and EKG (3)
  • EKG is neither very sensitive (only 29 of
    angiogram proven disease had ST,T or voltage
    changes)
  • Nor specific - Nonspecific T ? common
  • Resting EKG most useful for baseline and future
    comparison

16
CAD screening and EKG (4)
  • Stress testing (EKG only) more sensitive and
    specific than resting EKG, but many false (not
    specific enough
  • Still, only 1-11 w/ abnormalities suffered acute
    MI or sudden death when followed over 4-13 years
  • Addition of thallium scintigraphy scan proves
    more sensitive but less specific in low risk
    population.

17
CAD screening and EKG (5)
  • Only 1-11 w/ abnormalities suffered acute MI or
    sudden death when followed over 13 years
  • 0.045 (4/10,000) of resting EKGs will diagnose
    asymptomatic CAD

18
CAD screening and (EKG) - (7)
  • Stress testing OK in higher risk states - e.g.
    out of shape middle aged ex-athletes before
    embarking on exercise program- usually EKG w/o,
    e.g. thallium
  • Atypical chest pain w/ dyslipidemia, Obesity
    and/or hypertension, w/ thallium
  • EKG is most useful in the acute situation

19
Best application for Scanned Stress Testing
  • Diagnosis of chest pain (I.e. not a screening
    situation)

20
Criteria for CAD Screening I
  • The conditions must have a significant effect on
    the quality or quantity of life (YES).
  • Acceptable methods of treatment must be available
    for the condition (YES).
  • The condition must have an asymptomatic period
    during which detection and treatment
    significantly reduce morbidity or mortality
    (YES).
  • Treatment in the asymptomatic phase must yield a
    therapeutic result superior to that obtained by
    delaying treatment until symptoms appear (not
    settled).

21
Criteria for Screening II
  • Tests that are acceptable to patients must be
    available at reasonable cost to detect the
    condition in the asymptomatic period. Corollary
    Sensitivity and specificity must be appropriate
    for the risk status of the population being
    screened (NO and NO).
  • The incidence of the condition must be sufficient
    to justify the cost of screening (YES).

22
Significance of hypertension
  • Prevalence US said to be 58 million (20 of the
    entire population, adults and children)
  • Leading risk factor for stroke
  • When neglected, presents as hypertensive heart
    disease (LVH, pulmonary edema), CAD
  • Largely asymptomatic

23
Hypertension
  • Ranking risk factor for strokegt CADgt Renal
    Failuregt

24
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25
Pathophysiology of essential hypertension
  • 35 Caucasians and most other groups
    hypertension characterized by salt/water
    retention 65 African-Americans majority of
    elderly
  • 10 peripheral vascular resistance (PVR)
    (renin/angiotensin, catecholamines)
  • 55 mixed PVR/salt retention)
  • Hyperinsulinemia associated w/ volume dependent
    hypertension

26
Hyperinsulinemia associated w/ mineralo-corticoid,
probable contributor to volume dependent
hypertension
  • Salt/water retention driven hypertension responds
    to diuretics thiazides gt loop diuretics (except
    in rising creatinine)-
  • - and to salt restriction
  • What portion of most groups hypertension have
    pure salt sensitivity? 35
  • Which portion of African-Americans hypertension?
    67

27
Salt Restriction opportunity for primary
prevention of hypertension (Other mainstays of Rx
of hypertension ACEIs and ACERBs, Ca channel
blockers, ß blockers)
28
Definitions of Hypertension (HTN)
  • Three readings on separate
  • occasions (gt140/gt90) to make
  • the diagnosis, unless BP is
  • found at gt210/gt120

29
Htn in Children 95th-99th percentiles
  • Age group
  • Newborns _at_ 30 d
  • Infants
  • 3-5 years
  • 6-9 years
  • 10-12 years
  • 13-15 years
  • 16-18 years
  • SBP/DBP, mm Hg
  • 104-109 SBP
  • 112-117/74-81
  • 116-123/76-83
  • 122-129/78-85
  • 126-133/82-89
  • 136-143/86-91
  • 142-149/82-97

30
Physiologic Types of Hypertension
  • I Essential or Primary Hypertension (90-95 of
    all cases)
  • II Secondary Hypertension
  • 5-10 of all cases (pheo, primary
    aldosteronism, renovascular)
  • (Zollo The Portable Internist. Hanley and
    Belfus/Philadelphia and Moseby/St. Louis 1995)

31
Primary and secondary prevention HTN w/o drugs
  • Weight control to prevent HTN (and to prevent
    insulin resistance)
  • Control sodium intake to prevent 1/3 HTN useful
    adjunct in addtional 1/3
  • Stress management
  • Control of other aggravating risk factors
    e.g. smoking, dyslipidemia

32
Isolated Systolic Hypertension (ISH SBP140)
  • CVD risk
  • More common in elderly elderly more likely to
    have ISH likely to be diuretic responsive.

33
Factors in primary prevention of Htn in high risk
people
  • -salt restriction
  • -stress management
  • -weight control

34
Implications of hypertension and of diabetes re/
kidneys
  • Status of renal function

35
Major causes of chronic renal failure (not ESRD)
sub w/ Bakris
  • Diabetes mellitus 31.0
  • Hypertension 27.0
  • Glomerulonephritis 14.0
  • Obstructive uropathy 5.7
  • Polycystic renal disease 3.6
  • Others 5.7
  • Unknown 13.0

36
Diabetes The Most Common Cause of ESRD
Primary Diagnosis for Patients Who Start Dialysis
Glomerulonephritis
Other
13
10
No. of patients
700
Projection
95 CI
600
500
400
No. of dialysis patients (thousands)
520,240
300
281,355
200
243,524
100
r299.8
0
1984
1988
1992
1996
2000
2004
2008
United States Renal Data System. Annual data
report. 2000.
37
Prevention of End Stage Renal Disease by BP and
BS control
  • Tight control of blood sugar and of BP prevents
    ESRD in diabetics and hypertensives.
  • Diabetes Control and Complications Trial Research
    Grp. Diabetes Care 1995 United Kingdom
    Prospective Diabetes Study 1998

38
Recommendations for screening for HTN (USPSTF,
1996)
  • Screening for hypertension is recommended for
    all children and adults, i.e. BPs on all visits

39
Secondary Prevention of Complications of D/M
through control of BS, insulin resistance UKPDS
  • Metformin as good as S.U.s in BS control but MI
    mortality reduced by 39 w/ metformin (b/c
    reduces insulin)
  • Hgb A1C controlled to lt 7.0 instead of 7.9
    reduced retinopathy by 29, nephropathy by 33,
    and neuropathy by 40
  • (many now cut Hgb A1C lt 6.4

40
Dyslipidemia
  • Prevention and screening

41
ATP III criteria for lipid levels, ideal
  • LDL cholesterol lt 100mg/dL
  • Total cholesterol lt200mg/dL
  • HDL cholesterol 40 mg/dL (men) JAMA. 2001
    2852487-2497

42
Lipid levels when to apply diet
  • Total cholesterol start diet _at_ gt200
  • LDLC diet for 160 mg/dL
  • HDLC diet at lt 40
  • TCHDLC ratio gt 5.1 males, gt 4.1 females,
  • TG diet for gt 150

43
Dietary goals
  • Fats 30 total cal as saturated lt7
    polyunsaturated 10
    monounsaturated 20
  • Carbos 50-60 of cal complex
  • gt simple
  • Fiber 20-30 gm
  • Protein 15 of total calories
  • Cholesterol lt 200 mg/day

44
More liberal use of the HMG Co-enzyme A
inhibitors (statins)
  • Increasingly believed that people w/ mild to
    moderate risk factors benefit from statins
  • the foregoing includes even women and elderly
    (gt75 y.o.)
  • That LDL should not exceed 100 mg/dL
  • That everyone should have a lipid profile every 5
    years.

45
More liberal definition of risk status
  • From Framingham study, people w/ two risk
    factors should be treated as if they have already
    a diagnosis of CAD.
  • People w/ diabetes alone to be treated as if they
    have already a diagnosis of CAD.

46
Significance of CRP Ridker J.A.M.A. 2001
2852481-2485 Ridker New Engl J Med 2004
35220-8
  • Marker of over exuberant inflammatory response,
    relevant in endothelial injury and repair
  • Highest quartile of CRP exhibits RR of 1.5 times
    expected risk for atherosclerotic disease

47
CRP continued
  • AS is a disease of endothelial defectiveness -
    failure causes rupture of plaques
  • CRP levels, along with Total and Low Density
    Lipoprotein Cholesterol are reduced by statins

48
Recommendation for lipid screening
(USPSTF) USPSTF Guide to Clinical Preventive
Services Second Edition. Williams and Wilkins 1996
  • -periodic measurement of cholesterol for all men
    35-65 and women 45-65- and it may also be
    clinically prudent for healthy men and women
    65-75

49
Primary prevention of dyslipidemia
  • Weight control
  • Qualitative diet adjustments
  • Exercise

50
Prevention of Stroke (1)
  • First, control of risk factors
  • Htn, smoking, lipids, diabetes

51
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52
Screening for stroke susceptibility (2)
  • Carotid stenosis of 75 carries 2 risk of
    stroke/year.
  • ACAS study showed stroke reduction over a five
    year period to 5.8 - 4.8 from 10.5, by
    preemptive carotid endarterectomy (a reduction of
    relative risk of 55 J.A.M.A. 1995 273
    1421-28

53
Screening for stroke w/ carotid bruit (3)
  • Doppler ultrasound yields 87 sensitivity and 91
    specificity, for stenosis.
  • Carotid angiogram is gold standard.
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