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Epidemiology of Ischaemic Heart Disease

Incidence and Prevalence

An estimated 2.7 million people in the UK have coronary heart disease.2 The death rate from CHD in the UK remains one of the highest in Europe, exceeded only by Finland and Ireland. NHS in England reports 200,000 inpatient episodes for men and 100,000 for women related to IHD (approx. 5% all admissions for men and 3% for women). Mortality in men under 65 years of age is a significant cause of premature deaths, i.e. in 54.9/100,000 men in England compared with 14.4/100,000 for women. IHD mortality rates are lowest in the South East with highest rates in Northern urban areas and some London boroughs - largest difference is between Manchester at 105/100,000 and Chilterns at 26/100,000. 3 Approx. one quarter of all deaths among men and one fifth of deaths among women are due to IHD. In men aged 55-64 years, accounts for one third of all deaths. Approx. 30 million working days lost for men and over 4 million for women each year in Britain. Mortality from IHD increased steadily up until 1980 to reach a peak of 5372/million in England and Wales for men. Since then there has been an approx. 60% reduction in death from CHD in each age group, ascribed to less smoking, and the use of antiplatelet, thrombolytic, and beta-blocker therapy. Reported incidence of angina or earlier heart attacks are: 4
Age Men Women 50 years 3% 2% 60 years 10% 6% 70 years 21% 11%

Risk factors The aetiology of CHD is multifactorial. It is the result of interaction between polygenic, lifestyle, and environmental factors:

Family history Several regions of the human genome have been shown to be associated with either CHD or hypertension. A family history of CHD is a strong risk factor for MI and acts synergistically with other risk factors below. 5 Family history is significant if a male relative suffered a CHD event before 55yrs, or a female relative before 65yrs. Age Risk of death from IHD doubles with every 8 years of age with the death rates for women the same as for men 10 years younger.

Gender Rates of IHD-related death are 3-4x greater in men than in women across countries with differing levels of disease. Same risk factors for women as for men but absolute risk is less. Socio-economic status IHD is twice as common in social group V compared with group I. Related to many factors including diet, smoking, exercise, alcohol. Ethnicity There is a higher incidence of IHD in patients from India and Pakistan and a lower incidence in patient originating from Africa and West Indies. Diet and cholesterol Currently fat makes up 40% of total calories in the UK diet, with recommended intakes of around 33% being common (American Heart Association recommends 30%). Reductions to less than 10% may be required to have a major impact on CHD risk. Dietary fat is directly linked to levels of blood cholesterol. Saturated fat raises the cholesterol level and unsaturated fat reduces it. The high intake of saturated fat in UK explains the excessive incidence of CHD compared with other countries such as those around the Mediterranean. The increase in risk is on a continuum and there is no safe level. The lower the level the less the risk. A reduction of 0.6mmol/l AT ANY LEVEL reduces the risk by 20%. A change to a low fat diet can achieve this, whilst use of statins can lower the level by 1.8mmol/l and reduce risk by 60%. This can take 3 years to be reached. Dietary plant stanols/sterols (as in Benecol and Flora pro-activ margarines) may have a role in future. Eating fish or taking fish oil capsules has been shown to reduce IHD mortality, though the dose of omega-3 oil required is 10 times more than that consumed by fish-eaters. Regular fresh fruit and vegetables is believed to be protective but not clear to what extent, and may be part of an overall lifestyle pattern. The antioxidant phytochemicals, particularly flavonoids (found in red wine, black tea, and dark beer), appear to be protective, as are the vegetable proteins soy, and seitan. Increased intake in dietary fibre from cereals reduces risk, but can interfere with the absorption of certain vitamins and minerals. Foods rich in phytochemicals and vitamins, are also rich in fibre. Smoking Smoking cigarettes causes IHD to occur earlier - approx. 7 years on average. Blood pressure Excess salt intake is blamed for hypertension in Western countries. As with cholesterol there is no safe level and a small reduction in BP can have important benefits: 5.0/2.5mmHg lowering - 11% reduction in IHD 10.0/5.0mmHg lowering - 21% reduction in IHD Obesity Known to be associated with high blood pressure and cholesterol and low HDL as well as with insulin resistance. Those with a higher waist-hip ratio are at increased risk above that just for weight. Alcohol Consumption of 1-2 units alcohol reduces risk by 20% compared with teetotallers. Alcohol increases HDL cholesterol and reduces thrombotic risk. Higher levels of consumption increases risks from other causes. Apparently any form of alcohol is as good as another.

Insulin resistance and diabetes Only top 5-10% of population levels of fasting glucose are clearly associated with an increased risk of IHD. But with frank NIDDM there is a much greater risk than those associated with other risk factors and such patients would benefit greatly from reduction in other risk factors. Physical inactivity A level of physical activity sufficient to produce cardiorespiratory training (promoting endurance and muscle strength) clearly reduces the risk of IHD, but lower intensity activity (likely to concentrate on flexibility) may not. Serum homocysteine Homocysteine is an independent risk factor for IHD, likely to due oxidative damage to endothelium, platelet activation and thrombus formation. 10% of CHD risk in the population is attributable to homocysteine, 5-7% of the population having elevated levels. Supplementation of diet with folic acid (and possibly vitamin B-6) reduces incidence. Stress High levels of stress are not believed to associated with build up of atheroma. However evidence of a link between working conditions ("high demand/low control" type work) and CHD is accumulating, and stress reduction can reduce the risk of a second MI. CRP may be useful as a predictor, reflecting as it does inflammation. Aspirin and HMG-CoA reductase inhibitors may have a role in reducing plaque inflammation. Fibrinogen may have a role as an independent predictor.

References Used 1. Ness AR and Davey Smith G. in Oxford Textbook of Medicine, 4th Edition. Eds; Warrell DA et al. OUP 2003. 2. BHF Coronary Heart Disease Statistics 2004. 3. Otreba P et al An atlas of coronary heart disease mortality, hospital admissions and coronary revascularisatins in South East England; Published by the South East Public Health Observatory Press and the NHS Executive Nov 2003 4. Law M Epidemiology and prevention of Ischaemic Heart Disease (IHD); Wolfson Institute of Preventive Medicine. January 2003 5. Whaley MH, Blair SN; Epidemiology of physical activity, physical fitness and coronary heart disease.;J Cardiovasc Risk 1995 Aug;2(4):289-95.[abstract]Whaley MH, Blair SN. Epidemiology of physical activity, physical fitness and coronary heart disease. J Cardiovasc Risk. 1995; 2(4): 289-95. Acknowledgements EMIS is grateful to doctoronline.nhs.uk for facilitating draft authoring of this article and to Dr D J Ward for his additions. The final copy has passed peer review of the independent Mentor GP authoring team. EMIS 2003.
Last issued 08 May 2006