Prevention%20of%20Cardiovascular%20Diseases:%20Begin%20in%20Childhood!

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Prevention of Cardiovascular Diseases Begin in
Childhood!

• Ruth Collins-Nakai
• MD, MBA, FRCPC, FACC
• President
• InterAmerican Society of Cardiology

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Outline

• World status of CVDs
• Argentinean status of CVDs
• Prevention efficacy
• Recommendations re risk factors
• Role of CV specialist in prevention

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World Status of CVD

• Represents 30 of all deaths worldwide (15
  million deaths/year)
• Leading cause of death and disability
• CVD burden ? in developing countries
• Risk factors ? worldwide

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GDP spent on health
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Population per Physician
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Argentina CVD mortality females
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Argentina CVD mortality
females
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Argentina IHD mortality males
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Argentina Diabetes females
males
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Atherosclerosis A Systemic Disease
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Prevention Facts

• Defined Risk Factors in adults associated with
  accelerated atherosclerosis and CVD rates
• Atherosclerosis begins in childhood
• Extent of atherosclerosis in children correlated
  with same risk factors as in adults
• Strong JP et al JAMA 1999281727-735
• Berenson GS et al NEJM 19983381650-1656
• Williams CL et al Circ. 2002106143-160

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Early Appearance of Atherosclerosis Bogalusa
Heart Study
Prevalence of Fibrous Plaque Lesions
80
Aorta
Coronary Arteries
60

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20
0
2-15
16-20
21-25
26-39
2-15
16-20
21-25
26-39
Age (Years)
p 0.001 for trend toward increasing prevalence
with age in aorta and coronary arteries.
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The Evidence

• ?physical activity associated with ? life
  expectancy
• Direct association between obesity insulin
  resistance in children
• Direct association between obesity lipid levels
  in children
• Tracking BMIgtweightgtskinfold thicknessesgtlipidsgtB
  P
• Clusters of multiple risk factors persist
  strongly from child-to-adulthood

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Risk Factors for Atherosclerosis

• Smoking
• Obesity
• High blood pressure
• Physical Inactivity
• High blood fat levels
• Diabetes
• Positive family history
• Other (ethnicity, anger)

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Effect of Multiple Risk Factors on Probability of
CAD Framingham Study
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10-Year Probability of Event
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10
6
4
SBP 150-160 Cholesterol 6.2-6.8
- HDL-C 0.8-0.9 - - Diabetes
- - - Cigarettes - - - - ECG-LVH - -
- - -
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Recommendations

• Cardiovascular Health in Childhood (AHA
  Scientific Statement)
• Circ 2002106143-160
• Circ 20021071562-1566
• Canadian Cardiovascular Society Consensus
  Conference on Prevention of CVD The Role of the
  CV Specialist
• CJC 199915(supple.G)

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Smoking
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Tobacco

• Complete cessation for those who smoke
• No exposure to environmental tobacco smoke
• No new initiation of cigarette smoking or tobacco
  use

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Obesity

• Appropriate body weight (BMI for age)
• (www.cdc.gov/growthcharts./)
• Overall healthy eating pattern (limit salt, fat,
  calories sugar gt 2 years age)
• Balance Energy in energy out for weight
• Begin treatment before adolescence

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Trends in prevalence of overweight in
USA (CDC NHANES)

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15
10
5
0
1963-70
1971-74
1976-80
1988-94
1999
6-11 yrs
12-19 yrs
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Physical Activity

• Physical activity every day (60 minutes per day
  for children)
• Reduce/limit sedentary time (e.g.. TV maximum 2
  hours per day)
• May add resistance training to aerobic activity
  in adolescents

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Lipids Lipoproteins

• Total cholesterol lt4.4 mmol/L recommended
  (USAgt170mg/dL borderline gt200 mg/dL is ?)
• LDL-C lt2.85 mmol/L recommended (USAlt110mg/dL)
• Triglycerides lt1.5 mmol/L recommended (USA lt150
  mg/dL)
• HDL-C gt35 mg/dL recommended

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Effect of SBP and DBP onAge-Adjusted CAD
Mortality MRFIT
CAD Death Rate per 10,000 Person-years
80.6
48.3
43.8
38.1
37.4
34.7
31.0
25.3
25.2
25.8
24.9
24.6
23.8
160
13.9
16.9
12.6
11.8
12.8
20.6
140-159
10.3
11.8
8.8
8.5
9.2
120-139
lt120
100
90-99
80-89
75-79
70-74
lt70
Systolic BP (mmHg)
Diastolic BP (mmHg)
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Blood Pressure

• Systolic diastolic BPgt90th for age, sex and
  height is abnormal (www.nhlbi.nih.gov/health/prof/
  heart/hbp/hbp_ped.htm.)
• gt130/80 is almost always pathological in youth.
• Use proven effective therapies recommended for
  adults (CPGs)

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Diabetes

• Adequate nutrition (neither over nor
  undernutrition) of pregnant women Barker
  hypothesis
• Limit sugar intake
• Maintain normal weight for age height
• For type 1 diabetics, ongoing strict control (Hgb
  A1c)

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Other Risk Factors

• Ethnicity (esp. South Asian / aboriginal/black/His
  panic)
• Low socioeconomic level
• Social isolation
• Depression
• Pregnancy (HTN and gestnl diabetes)
• Emerging risk factors

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Childhood Abuse

• Adverse childhood experiences (ACEs)
• 1.7x ? risk with emotional abuse
• 1.7x ? risk with crime in household
• 1.3x ? risk with emotional neglect
• 1.3x ? risk with substance abuse
• Depressed affect OR 2.1
• Anger OR 2.5
• 7 or gt ACEs ? risk almost 4x
• Dong M et al CIRC 110 2004

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Clinical Application of the Concept of Risk
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Vascular, unstable
Pluri-vascular
Diabetic risk factors
Vascular
Diabetic
Asymptomatic risk factors
Asymptomatic
Symptomatic
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Economic Burden of Coronary Artery Disease (CAD)
Direct and Indirect Cost of CAD Country (not
adjusted for inflation)
US (2000) 118.2 billion USD Canada (1993) 19.6
billion CDN (15.2 of total economic burden of
illness) UK (1996) 10 billion Germany (1996) 112
billion DM Taiwan (1991) 9.0-11.9 billion new
Taiwan Sweden (1994) 276 billion SEK
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BMI
lt75ile
75-85ile
85-95ile at risk for ow
gt95ile overweight
Reaffirm healthy Habits f/u annually
Assess family history, food habits, activity
Council to change food intake increase
physical activity
Council to change food intake increase
physical activity
Assess RF If gt1 RF, treat as gt95ile
Assess RF Treat RFs Involve family
Nesbitt SD et al Ethnicity Disease 142004
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Role of Cardiovascular Specialist

• Education of other health care personnel
• Advocate for heart healthy public policies
• Treat individual patients, including children
  with significant risk factors.

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Conclusions

• The burden of global CVD is increasing
• The burden of risk factors is rising alarmingly
  in children and youth
• Cardiovascular specialists have an obligation to
  lead in prevention
• Educate, Advocate, Treat

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Gracias!
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