Cardiovascular Diseases

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Cardiovascular Diseases

• LT Latona M. Olic, PharmD
• October 9, 2003

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Objectives

• Describe the past and current cardiovascular
  health status trends among Native Americans (NA)
  and Alaskan Natives (AN)
• Review cardiovascular disease prevalence among NA
  and AN
• Discuss risk factors that contribute to
  cardiovascular disease in NA and AN

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Objectives

• Review treatment guidelines for coronary heart
  disease in NA and AN
• Understand how nutrition, lifestyle modification
  and pharmacotherapy play a role in primary and
  secondary prevention of coronary heart disease
• Understand specific traditional and cultural
  needs in disease management

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Introduction

• Cardiovascular disease (CVD) not considered a
  population health problem for NA AN until the
  latter part of 20th century
• Past Lower death rate than general population
• Present Leading cause of death, equal to or more
  than general population

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Introduction

• One study found at a Navajo hospital, out of
  10,000 admissions during 1949-1952 no reported
  acute myocardial infarction
• Also during that time among southwestern Indians
  low frequency of smoking, HTN and
  hypercholesterolemia
• Increase prevalence possibly related to a change
  from traditional to westernized lifestyle

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Introduction

• Since mid-1960s mortality rates from CVD has
  declined by more than 50 in general population
• Not so in NA population, where the rates have
  increased
• The Treatment of Dyslipidemias in Native
  Americans December11-13, 2000 Scottsdale, Arizona
• http//www.ihs.gov/MedicalPrograms/Cardiology/Lipi
  dGuidelines.pdf

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Total Cardiovascular Disease

• Includes
• Coronary Heart Disease (CHD)
• Hypertension (HTN)
• Cerebrovascular Disease
• Peripheral Arterial Disease
• Rheumatic Heart Disease
• Congenital Heart Disease

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Total Cardiovascular Disease

• Most significant heart disease among Indian
  population is CHD
• 1987 the age- and sex- adjusted prevalence of
  CHD was noted to be the same as general
  population (9.8 vs. 10)

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Strong Heart Study (SHS)

• Multitribal prospective cohort study including
  45,000 individuals age 45-74
• Mortality rate among NA 194.6 compared with
  general population which was 173.9 (per 100,000
  people) 1997
• Higher prevalence of major electorcardiographic
  abnormalities suggestive of CVD

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Risk Factors

• Risk factors are a major determinant of CVD
• Diabetes
• Smoking
• Lipid profile
• Physical Inactivity
• Body Mass Index
• Alcohol Consumption

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Diabetes

• Profound effect on CVD (strongest risk factor)
• Correlation the longer duration with DM the more
  likely CHD
• Higher rate of DM in NA and AN than general
  population
• Insulin Resistance and Syndrome X

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Diabetes

• Pima Indians (ages 45-74) 70.9 of females and
  64.7 males have DM
• Navajo 17 of men and 25 of women age 20-91
  have DM (4x US estimates)
• Pine Ridge 40
• 75-80 of patients (all populations) with DM die
  from CVD

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Smoking

• Leading risk factor but not for every tribe
• Pima Indians it was not a significant risk factor
• A rising risk factor- Navajo study found that 1
  in 5 Navajo high school students smoke
• At Pine Ridge- 41 with DM are smokers

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Lipid Profile

• Pima cohort study- HDL as a predictor of CHD
• HDL levels lower than general pop
• HDL levels even lower in DM patients
• Other groups with low HDL included Pima, Navajo,
  Indian women in Minneapolis

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Lipid Profile

• Total cholesterol In general NA have lower
  cholesterol levels then general population
• Lower rates of hypercholesterolemia
• Navajo men have serum cholesterol levels equal to
  general population
• How does this fit in the big picture?

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Physical Inactivity

• In US PI poses a greater estimated risk for CHD
  than obesity, smoking, and hypertension
• Studies confirm lower rates of physical activity
  and exercise in NA population

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Physical Inactivity

• CDC Intertribal Health Project
• Inactivity reported by 28
• More common in women, older, less educated, less
  income and unemployment

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Body Mass Index

• Obesity as a risk factor
• SHS study The waist-hip ratio was not found
  significantly associated with prevalent CHD as
  now stated in the ATP III guidelines

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Alcohol Consumption

• Relationship not evaluated in NA population
• In SHS study prevalence of alcohol consumption
  less than general population
• Binge drinking more common among those who did
  drink

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Multiple Risk Factors

• Paxcua Yaqui adult study (1990)
• 86 of participants had at least one major risk
  factor DM, HTN, hypercholersterolemia, obestiy
  or smoking
• 52 had 2 or more risk factors

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Coronary Heart Disease

• Prevalence
• Early studies of Southerwestern tribes and AN
  reported very low prevalence rates
• Men of Northern Plain tribes had relatively low
  incidence rates of MI compared to participants in
  the Framingham Study
• Recent decades, acute MI has nearly tripled in
  Southwestern tribes

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Treatment of Dyslipidemias

• Guideline Development Conference The Treatment
  of Dyslipidemias in Native Americans December
  11-13, 2000 Scottsdale, Arizona
• Several differences between these guidelines and
  the NCEP ATP III guidelines

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Treatment of Dyslipidemias

• Differences
• These guidelines focus more on the metabolic
  syndrome (Syndrome X)
• Risk factor counting approach used in determining
  lipid goals and treatment choices rather than ATP
  III Framingham risk factor assessment
• LDL goal of lt 130 after lifestyle modifications
  for patients with 2 or more risk factors more
  aggressive than ATP III

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Guidelines-Rationale

• Elevated LDL
• Target lipoprotein when treating dyslipidemia
• Studies have shown that by lowering LDL,
  atherosclerotic plaque and morbidity and
  mortality are reduced
• NA have lower average LDL than general population
• Linear relationship between LDL and risk for CVD
  of concentrations gt 70 mg/dl

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Guidelines-Evidence for the Benefits

• Evidence for lowering LDL
• No studies performed on NA on safety and efficacy
  of cholesterol-lowering drugs (we have to go by
  other population evidence)
• HMG-CoA reductase inhibitors (Statins) most
  effective at lowering LDL 5 large, long-term
  clinical trials
• Other agents for lowering LDL bile-acid binding
  resins, fibric acid derivatives and niacin

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Guidelines-Recommendations

• LDL goals

Risk Level LDL-C Goal IFG/IGT/DM/CVD lt100
mg/dL 2 risk factors lt 130 mg/dL 0-1 risk
factors lt 160 mg/dL
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Guidelines-Recommendations

• Actions to meet LDL goals

Risk Level Action IFG/IGT/DM/CVD Diet/Lifestyl
e/Pharm. 2 risk factors Diet/Lifestyle/Pharm 0-1
risk factors Diet/Lifestyle
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Guidelines-Recommendations

• Order of priority for drugs recommenced for
  lowering LDL
• Statin
• Resin (if nondiabetic and without triglyceride
  elevation)
• Niacin (depending on glucose control)

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The Metabolic Syndrome

• What is it? Lipid abnormalities ?LDL, ?TG, ?
  HDL
• Often associated with HTN, central obesity and
  insulin resistance

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The Metabolic Syndrome - Recommendations

• Lipoprotein evaluation
• Patients with atherosclerosis, DM, IGT, IFG and
  multiple risk factors
• Total cholesterol, TG, LDL-C and HDL
• Patient with DM with significant TG elevations
• Direct LDL

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The Metabolic Syndrome - Recommendations

• Medications for addressing metabolic syndrome in
  NA populations
• Statins when TGlt400 mg/dl
• Resins not recommended with borderline and high
  TG
• Fibric Acid derivatives 1st line choice with TG
  gt 400 mg/dl
• Niacin worsening of glycemic control?

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The Metabolic Syndrome - Recommendations
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Risk Assessment

• Risk level identification 10-year risk of
  cardiac events-Framingham risk score
• High risk greater than 20
• Intermediate risk 10-20
• Lower risk 10
• Framingham data not specific to NA population but
  must suffice

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Risk Assessment

• Motivations tool for patient compliance
• Lipid levels and risk evaluation in general
  population should be performed every 5 years
• All non-DM patients with CV risks gt 45 years
  should be on ASA 81-325 qd
• All DM patients gt 30 should be on ASA 81-325 qd

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CV Health Promotion Programs Session

• Recommendations
• Physician directed multidisciplinary programs
  CHD risks managed by RPh, RN, RD and LPNs
• Mid-level providers must be certified and current
  in risk reduction practice
• Programs need to address cultural, psychological
  and social values, motivations interviewing,
  exercise, nutrition, weight loss, tobacco
  cessation, DM, HTN and dyslipidemias

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Effective Lifestyle Modifications

• Incorporating healthy habits on a daily basis
  improves dyslipidemia and decreases morbidity and
  mortality
• Regular physical activity and balanced nutrition
• Personal Plans need to be tailored to specific
  traditions and cultures

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Effective Lifestyle Modifications

• The Diabetes Prevention Program Study showed a
  58 reduction in the onset of type2 DM with diet
  and lifestyle interventions

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Dietary Recommendations

• 2000 AHA Dietary Guidelines should be followed.
  Specifics include
• Reduction in sugar-based beverages and juices
• Reduction in total calorie intake
• Reductions in total fat, saturated fat and trans
  fatty acids
• Increase in dietary fiber and complex
  carbohydrates
• Increase intake of vegetables and whole fruit

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Dietary Recommendations
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Physical Activity Recommendations

• Guidelines from the Surgeon General and the AHA
• Unless contraindicated, level of activity should
  be increased up to 30-60 minutes every day

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Lifestyle Recommendations

• Tobacco cessation
• Patients with BMI gt 25.0 should go through formal
  weight management programs
• Behavior modification of inappropriate food
  avoidance

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IHS Programs

• Diabetes programs
• Tobacco cessation programs
• Lipid clinics
• Coagulation clinics

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References

• Rhoades, ER ed., American Indian Health
  Innovations in Health Care, Promotion, and
  Policy. 1st edition. 2002.
• Galloway, JM ed., Primary Care of Native American
  Patients Diagnosis, Therapy and Epidemiology.
  1st edition. 1998.