Cardiovascular Disease from the Canadian and International Perspectives

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Cardiovascular Disease from the Canadian and
International Perspectives
Canadian Heart Health Strategic Action
Plan May 28, 2007

• Dr. Sonia Anand MD, PhD
• Associate Professor of Medicine
• McMaster University

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A radical approach aims to remove the underlying
impediments to healthier behaviour. the first or
medical approach is important, but only the
social and political approach confronts the root
causes.
Rose, Geoffrey, 1992
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Overview

• Global Burden of CVD
• Canadian Burden of CVD
• Ethnic Variations in Risk factors
• Association between Risk factors and CVD
• Strategies for Prevention
• Call for Action

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CHANGE IN THE RANK ORDER OF DISEASE BURDEN FOR 10
LEADING CAUSES, WORLD, 1990-2020 (DALYS)
1990
2020
1 Coronary heart disease 2. Major
depression 3. Traffic accidents 4. Stroke 5.
COPD 6. Lower resp infections 7. TB 8.
War 9. Diarrhoeal disease 10. HIV
1. Lower resp infection 2. Diarrhea diseases 3.
Perinatal 4, Major depression 5. Coronary heart
disease 6. Stroke 7. TB 8. Measles 9. Traffic
accidents 10. Cong anomalies
Murray and Lopez, GBD
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Worldwide Deaths from Cardiovascular Causes
Millions of Deaths from Cardiovascular Disease
Reddy K. N Engl J Med 20043502438-2440
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Age-standardized mortality rates of CVD and
Cancer in Canada
Per 100,000
CVD IHD, CBVD, DM, ATH
Statistics Canada
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Canadas Modifiable Risk Factors
The Growing Burden of Heart Disease and Stroke in
Canada 2003
Source   Statistics Canada, Canadian Community
Health Survey
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Comparing Ethnic Groups
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Aboriginal
Immigrants
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74

• gt922,000 Chinese
• gt723,000 South Asians
• gt1,100,000 Aboriginal people

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Mortality for CHD and Cancer Age 35
74(1979-1993)
Sheth et al, CMAJ 1999
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SHARE Study of Health Assessment and Risk in
Ethnic Groups
Random Sample - Europeans, South Asians, Chinese,
Aboriginal

• Environmental
• Factors
• Lifestyle
• Nutrition
• Psychosocial
• Cultural

• Risk Markers
• Lipids
• Coagulation
• Glucose
• BP
• Antioxidants
• Homocysteine

• Subclinical Disease
• Carotid
• Ankle Arm BP
• LVH
• Micro Alb.

• Clinical
• Events
• CAD
• Stroke
• PVD

Genetic Factors
Anand S et al Can J Cardiol 1998
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Obesity and Abdominal Fat

BMI 30 WHR gt 0.85 (female)/1.0 (male)
Age and sex Adjusted
Anand et al SHARE Lancet 2000/1
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? Glucose Dysglycemia
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Age-Adjusted Prevalence of Metabolic Syndrome in
Canada
Age-Adjusted
Anand et al Circulation 2003
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CVD Prevalence comparing Ethnic Groups in Canada
Age and Sex Adjusted
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Relationship of Glucose Factor to BMI in
Non-white ethnic groups
BMI21
BMI 30
Razak et al Circ 2005
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SHARE- Nutrition
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EVOLUTION OF RISK FACTORS IN URBAN MIGRANTS
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Risk of CVD and Social Disadvantage
Aboriginal and South Asian ?
Aboriginal and South Asian ?
Chinese ?/ ?
Anand, S. S et al. Int. J. Epidemiol. 2006
351239-1245 doi10.1093/ije/dyl163
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Risk Factor Frequency Varies

• Are the same risk factors important in all ethnic
  groups, age groups, and women and men?

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INTERHEART Design

• Cases First Acute Myocardial Infarction
  (n15,152)
• Controls Matched to cases by age (/-5 yr
  and sex) at each site (n14,820)
• Data collected from 262 sites in 52 countries

Coordinated by the Population Health Research
Institute, McMaster University, Canada
Ounpuu S et al Am Heart J 2001
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INTERHEART gt 27,000 Cases and Controls
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INTERHEART Global Case-Control Study Nine
Modifiable Risk Factors

• Smoking
• Elevated Lipids ? ApoB/Apo A ratio
• Diabetes
• Hypertension
• Abdominal Obesity ? Waist to Hip Ratio
• Physical Activity gt 4 hrs/week
• Alcohol 3 drinks/week
• Fruit and Vegetable Consumption Daily
• Psychosocial Stress Work/home stress,
  depression, financial stress, locus of control

• gt27,000 subjects
• 52 Countries
• 6000 women
• gt 12,000 gt age 60 yrs

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Risk of MI associated with Risk Factors in the
Overall Population
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Population Attributable Risk by Region and Overall
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INTERHEART Decreased Risk of AMI with Avoidance
of Smoking Daily Fruits/Veg, Reg Phys Activity
Alcohol
0.35 0.70 0.86
0.91 0.24 0.21
0.19
1.0
Potential to reduce AMI by 80
0.5
OR (99 CI)
0.25
0.125
no smk
Frt/Veg
Exer
Alc
Nosmkfvg
exer
alc
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Independent risk of MI associatedwith 2 markers
of obesity
WHR adjusted for age, sex, smoking, region
BMI
BMI - adjusted for age, sex, smoking,
region WHR
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INTERHEART DIETARY ANALYSIS

• Methods
• 6,530 cases and 10,792 controls
• 19 items food groups questionnaire
• Dietary Patterns
• Prudent diet raw and cooked vegetables, legumes
  and fruits
• Oriental diet tofu, soy sauce and green leafy
  vegetables
• Western diet dairy, fried foods and meats (high
  in saturated fats)

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INTERHEART Relative Risk of MI by Dietary Type
? 29
? 24
Adjustment factors Age, sex, region, BMI, WHR,
physical activity, alcohol intake, smoking,
apoB/apoA1, psycho-social factors, and education
Iqbal R et al 2006
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Risk factors the same, Frequency Varies

• Risk factors for MI are the same for all ethnic
  groups, young and old,
• and women and men.

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Association between Risk factors and CHD is
similar between ethnic groups
Disease
Risk Factors
Determinants
Consistent between ethnic groups
Environment
Dyslipidemia
Diet Quality Physical activity Stress Air
Pollution
Dysglycemia
Adiposity
Blood Pressure
CHD
Smoking
Psychosocial Stress
Genetic Factors
Physical Inactivity
ETOH
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Prevention and Treatment of Risk Factors/CVD
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Frequency of INTERHEART RISK Factors in Cases
and Controls
Number of Subjects
Number of INTERHEART Risk Factors
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Risk Factors are Ubiquitous in the Population
We are all at Risk

• 80 of Canadians have 1 Risk Factor
• 30 of Canadians have 2 Risk Factors
• 11 have 3 or more Risk Factors

Source    Statistics Canada, Canadian Community
Health Survey
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A population strategy of prevention is necessary
where risk is widely diffused through the whole
population.
Rose, Geoffrey
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RCT Evidence that Altering Risk Factors Lowers CHD
Iestra et al Circulation 2005
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How can we prevent the majority of premature CHD?
Can we prevent 90 of MI in young and middle age
NOW? NO Can we prevent gt90 of MI in young and
middle age in the foreseeable future? YES
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Prevention of Cardiovascular Disease - Individual
Approach
Individuals with Risk Factors for CVD
Individuals with CVD
Determinants of Risk Behaviors in a Population
GOAL
Interventions with a Preventive Focus
Interventions with a Socio-Economic Political
Focus
Interventions with a Clinical Focus
Type of Strategy

• Taxing Tobacco
• Subsidizing healthy foods
• Promote Physical Activity by improving Built
  Environment

Identifying treating ? Cholesterol or
Hypertension Smoking cessation

• Lipid Lowering
• Aspirin
• Beta blockers
• ACE-inhibitors
• Appropriate revascularization

Examples
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TREATMENT, 95 of Resources
High- Risk Treatment Intervention Approaches
Policy and Environmental Change
Risk Factor Detection and Control
Behavior Change
Emergency Care or Acute Case Management
Rehabilitation or Long-term Case Management
End-of-Life Care
PREVENTION, 5 of Resources
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Greatest Gains in Preventing CVD Population
Approach
Optimal Distribution
Present Distribution
of Population
High Risk
10 Year Cardiovascular Disease Risk
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Much can be done by individuals themselves to
improve their own health prospects, but whether
or not they will actually take such action
depends substantially on economic and social
structures for which governments are
responsible.
Rose, Geoffrey
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Prevention of Cardiovascular Disease Population
Approach

• Lipid Lowering
• Aspirin
• Beta blockers
• ACE-inhibitors
• Appropriate revascularization

Interventions with a Clinical Focus
Determinants of Risk Behaviours in a Population
Individuals with CVD
Individuals with Risk Factors for CVD
GOAL
Interventions with a Socio-Economic Political
Focus
Interventions with a Clinical Focus
Interventions with a Preventive Focus
Type of Strategy

• Taxing Tobacco
• Subsidizing healthy foods
• Promote Physical Activity by improving Built
  Environment

• Lipid Lowering
• Aspirin
• Beta blockers
• ACE-Inhibitors
• Appropriate revascularization

• Identifying treating
• Cholesterol or Hypertension
• Smoking cessation

Examples
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Intervening on the causes of CV risk factors
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Change in commuting patterns in the US (from
1980 to 2000)








Commuting in America III - A Pisarski, American
Highway Users Alliance Census Bureau
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Leading risk factors for disease burden in 2000
by development category ( total DALYS)
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Finlands Decline in CHD Mortality over 20 years
? Dairy Product, ? Vegetables, ? Salt, ?Animal
fats
National Strategy
BMJ. 1994 Jul 2309(6946)23-7
Age
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Decline in Risk Factors in men in Finland
Men aged 35 63
BMJ. 1994 Jul 2309(6946)23-7
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How can we prevent 90 of MI by 2030?

• Evaluate commnity interventions to reduce risk
  factors that are modifiable such as abdominal
  obesity
• 2. LARGE reductions in multiple risk factors are
  needed
• 3. Practically ALL adults in Urbanized Societies
  have abnormalities of at least one risk factor.
• Treat all? (e.g. Polypill)
• Prevent the development of risk factors (Societal
  interventions - i.e. tobacco policy, community
  re-design, food supply)

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Canadian Landscape

• Need for Public Health Programs to unite against
  CV Risk Factors (which overlap with Cancer RFs)
• Partnerships at multiple policy levels (National,
  Provincial, Regional)
• Need for Target setting and Evaluation of
  Progress

Robinson et al 2007
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The current social, occupational, and national
inequalities in health will not be much
influenced by health education, for they reflect
the way that societies are organized. We already
know what is desirable the obstacles to its
achievement, which prevent the majority from
having what some already enjoy, are substantially
economic, industrial, and political.
Rose, Geoffrey, 1992