DESCRIPTIVE EPIDEMIOLOGY
ANALYTIC EPIDEMIOLOGY
Incidence Prevalence
Triad Epidemiology Host Agent - Environment
Risk Factors
Diagnostic Tools
Therapy, Prognosis
Cardiovascular
disease is caused by disorders of the heart and blood vessels, and includes coronary heart disease (heart attacks), cerebrovascular disease (stroke), raised blood pressure (hypertension), peripheral artery disease, rheumatic heart disease, congenital heart disease and heart failure.
The
major causes of cardiovascular disease are tobacco use, physical inactivity, and an unhealthy diet.
Predispose
factors : Age, Gender, Family history, Behavior, Sanitation, etc Risk factors : Obesity/Malnourished, Hypertension Dyslipidemia, Impairment of Glucose Control, and Systemic Inflammation, etc
Clinical
Smoking
raises risk of atherosclerotic disease and potentiates myocardial infarction (MI) Smoking cessation reduces the risk of MI and mortality by 36%
Smoking
cessation : education about the danger of smoking and intervention with nicotine replacement and bupropion Relapse rate are high in the absence of education and encouragement.
Hypertension Atherosclerotic
Coronary Heart Disease and Peripheral Vascular Disease Congestive Heart Failure Congenital Heart Disease Valvular Health Disease Cardiac Arrhythmias
SKRT
2001
6 % HTN at 25-34 yr 15 % HTN at 35-44 yr 43 % HTN at > 55 yr 2/3 uncontrolled HTN patients at > 60 yr will have CHD, MCI, or Stroke within 5 year
Risk
of HTN is regulated by genetic background and environmental factors For every 20/10 mmHg increase BP above 115/75 mmHg, risk of CVD doubles (Chobanian et al, 2003)
Prevalensi
hipertensi pada penduduk umur 18 tahun ke atas di Indonesia adalah sebesar 31.7 %
Angka
JAMA. 1990;263:1795-1801
The
reduction of BP, reduces risk of acute cardiovascular events, progression of atherosclerosis, and end organ injury
mmHg SBP reduction reduces 14 % stroke death and 9 % CVD death (Chobanian et al, 2003) mmHg DBP reduction has benefit for prevention (Cook NR, 1996)
Atherosclerosis
begins in childhood and evolves over decades (Freedman et al, 1988), affecting > 85% adults > 50yr old (Tuzcu et al, 2001)
Causes
Risk
High
HDL level reduce the risk of developing CAD (Toth, 2001) Patients with familial low HDL have increase risk of premature CAD (Toth, 2003) Patients with familial high HDL are relatively resistant to CAD (Toth, 2004) The more elevated level of HDL, the lower the risk for CAD
Risk
Negative : HDL > 60 mg/dl Positive : Cigarette smoking HDL < 40 mg/dl (men), < 50 mg/dl (women) BP > 140 / > 90 (or use of antihypertensive agents) Family history of premature CAD (CAD in male first degree relative < 55 yr; CAD in female first degree relative < 65yr) Age (men >=45 yr; women >=55 yr)
Risk Assessment Tool for Estimating 10-year Risk of Developing Hard Coronary Heart Disease (Myocardial Infarction and Coronary Death) The risk assessment tool below uses recent data from the Framingham Heart Study to estimate 10-year risk for hard coronary heart disease outcomes (myocardial infarction and coronary death). This tool is designed to estimate risk in adults aged 20 and older who do not have heart disease or diabetes. Use the calculator below to estimate 10-year risk. Age: Gender: Total Cholesterol:
190
35
HDL Cholesterol:
Smoker: Systolic Blood Pressure:
Calculate 10-Year Risk
46
mg/dL
No Yes Yes mm/Hg No
110
Diet
Genetic predisposition
Systemic inflammation
Hyperuricemia Change in Adipose hormones Endothelial dysfunction
Insulin Resistance
Hypertension
Diabetes
Textbook of Family Medicine, Rakel, 07
CVD
The
incidence of Metabolic Syndrome increases in men and women as a function of age (Ford et al 2002, Alexander et al 2003)
Patients
with Metabolic Syndrome had 3.77 fold increase in risk of CVD mortality compared to patients without it (Lakka et al 2002)
Defining Level Men : Waist > 90 cm Women : Waist > 80 cm >=150 mg/dl Men : < 40 mg/dl Women : < 50 mg/dl >=130 / >=85 mmHg >=100 mg/dl
Patients who have ANY THREE (3) of five risk factors meet criteria for the metabolic syndrome
clinical syndrome resulting from the inability of the heart to meet metabolic requirements of the body at normal filling measure Patient with CHF should have their CVD risk factors controlled aggressively Target BP for CHF patients <130/<80 mmHg Target BP for CHF patients WITH DM <125/<85 mmHg
An
illness of children and adolescents with the average age of onset 8-10 yr with pharyngitis, caries dentis (bad oral hygiene), poverty, crowded living conditions, and difference in access to or utilization of medical care
Associated
Nepal
: High rates of RHD may not relate to increased prevalence of streptococcal infection, but to inadequate antibiotic therapy (proper dosage and duration) of streptococcal pharyngitis. giving penicillin to school children with pharyngitis (prior to confirmation of its etiology), can reduce the attack rate of rheumatic fever by ten folds.
Philippines:
Patients
with established cardiac complications must be regularly followed-up. requires cooperation and understanding of prognosis by patients and relatives and counseling on the doctors part
This
Tetralogy Fallot
Pulmonary Stenosis Patent Ductus Arteriosus Idiopathic Pulmonary Artery Dilatation
Only
1% of the children with congenital heart disease are today properly treated in Indonesia.
The
lack of the information and education on the part of the patients Uneven distribution of doctors A shortage of pediatrician A shortage of funding, both privately and publicly Number of cardiac surgery hospital
17.528.000
CARDIOVASCULAR DISEASES
7.586.000
CANCER
2.830.000
HIV/AIDS
TUBER-CULOSIS MALARIA
4.057.000
CHRONIC RESPIRATORY DISEASE
1.125.000
DIABETES
Thailand Vietnam
Singapore Filipina
COUNTRIES
336
274
361
291
mortality
106
314
428
140 182 141 188
0 100 200 300 400 500
Australia
United Kingdom
Canada
United States
MORTALITY RATE
Pharmacology
Drugs
Non
Pharmacology (health education/ counseling) on : Diet, Exercise, Smoking Cessation, Drugs compliance
Individual Perceptions
Likelihood of Action
Risk Factors
Modifiable Diet Physical activity Tobacco Alcohol Non-modifiable Age Genetic
Risk Factors Modifiable High lipids High Blood. Pressure. High Blood. Glucose. Obesity Malnourished
Promotion
Prevention
A man, 58 years old, sees his family doctor because of chest pain. He had been well until 2 weeks ago, when he noticed tightness in the center of his chest when he was walking uphill.
Remember Risk Factors (Biopsychosocial)
Died 60 of CVD Died ? of DM
58
Due to lots of contributing factors and broadintegrated disease management : Continuing care and monitoring are important to provide good health services for cardiovascular disease Educational approach and family participation are needed for : Patient to cope with the disease Getting patient and familys independence for improving/maintaining health status
Menanggulangi
kemiskinan dan kelaparan Mencapai pendidikan dasar untuk semua Mendorong kesetaraan gender dan pemberdayaan perempuan Menurunkan angka kematian anak Meningkatkan kesehatan ibu Memerangi HIV/AIDS, malaria, dan penyakit menular lainnya Memastikan kelestarian lingkungan hidup
Riskesdas 2007 Profil Kesehatan Indonesia 2005 www. americanheart.org Toth PP, et al: Cardiovascular Disease. In: Rakel RE, et all (ed): Textbook of Family Medicine, 7th ed. Philadelphia, Saunders Elsevier, 2007:735-805 Branch WT, et al (ed): Cardiology in Primary Care, Intl ed. New York, McGraw-Hill, 2000 Fletcher RH, et al: Clinical Epidemiology the essentials, 2 nd ed. Baltimore,Williams & Wilkins, 1988 Glanz K, et al: Health Behavior and Health Education, 2 nd ed. San Francisco, Jossey-Bass Publishers, 1997 Affandi M. Penyakit Jantung Bawaan: Apa yang harus dilakukan?. Cermin Dunia Kedokteran no 31 A Ibrahim, et all. Rheumatic Heart Disease: How Big is the Problem?. Med J Malaysia vol 50 no 2 June 1995 Balaban DJ: Epidemiology and Prevention of Selected Chronic Illnesses. In: Cassens BJ (ed): Preventive Medicine and Public Health, 2nd ed. Philadelphia, Harwal Publishing,1992:135-138