EPIDEMIOLOGY OF CORONARY HEART DISEASE

1
EPIDEMIOLOGY OF CORONARY HEART DISEASE
Australias Largest Health Problem 20 063 deaths
(18 of all deaths in 2002)
Rising prevalence in last decade Death rates
21.4 higher in disadvantaged (2000
2002) Indigenous Australians die 2.6 times faster
Heart, Stroke and Vascular Disease Australian
Facts 2004, AIHW and National Heart Foundation
File reference
2
ACHIEVEMENTS IN CARDIOVASCULAR HEALTH

• CHD death rates down 70 since 1967
• Data are age-adjusted
• Decrease in acute events (prevalence of certain
  risk factors)
• Decrease in case-fatality rates and improved
  treatments

NHF 2004
3
At-risk individuals and groups
General population
CHD patients
Heart Failure
Acute Presentation (ACS)
4
Acute Coronary Events in persons with and
without a history of prior admission for IHD WA
1995-97
CHD death and nfMI. (Excludes
revascularisation procedures)
M. Hobbs (personal communication) (Not for
reproduction)
5
NPCC CHD MONTHLY MEASURES

• Percentage of patients with CHD on aspirin
• Percentage of patients with CHD who are on a
  statin
• Percentage of patients who have had an MI in past
  12 months and who are on beta blockers
• Percentage of patients with CHD whose last
  recorded BP within the last 12 months was
  lt140/90mmHg

NPCC
6
ASPIRIN META-ANALYSIS (195 trials, 144 000
patients)
Benefit per 1000 patients (SE) Scenario No.
of nf MI nf Stroke Vascular Serious trials deat
h vasc.event AMI (mean treatment 15 13 (2) 2
(1) 23 (4) 38 (5)1 month) plt0.0001 p0.02 plt0.00
01 plt0.0001 Previous MI (mean 12 18 (3) 5 (1) 14
(4) 36 (5)treatment 2 years) plt0.00001 p0.002 p
0.0006 plt0.0001 Acute isch. stroke 7 NA 4 (2) 5
(2) 9 (3)(mean duration 3 wks) p0.003 p0.05 p
0.0009 Previous isch. stroke/ 21 6 (2) 25 (5) 7
(4) 36 (6)TIA (mean duration 3
yrs) p0.0009 plt0.0001 p0.04 plt0.0001 Other
high risk groups 140 NA NA NA 22 (3)(CAD, PAD,
high risk Plt0.0001of embolism)
Adapted from Antithrombotic Trialists
Collaboration. BMJ 200232471-86
Aspirin
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ESTIMATED BENEFITS AND HARM OF ASPIRIN FOR
PATIENTS AT DIFFERENT LEVELS OF CHD RISK
Adapted from US Preventive Services Task Force
Report, 2003
Aspirin
8
Dose-response relationship with ASA
ASA dose odds
reduction
5001500 mg daily
160325 mg daily
75150 mg daily
lt75 mg daily
23 2 (plt0.0001)
Any ASA dose
1.0
0.5
0.0
1.5
2.0
Control better
ASA better
N60,000
Antithrombotic Trialists Collaboration. BMJ
200232471-86
9
Cumulative hazard rates for CV death/MI/stroke
CURE
Cumulative hazard rates
placebo11.4
clopidogrel 9.3
RR 0.80 (0.72-0.90)plt0.001
30 d - End of studyRR 0.82 (0.70-0.95)
0
3
6
9
12
Months of follow-up
No of pts
5778 5864
4660 4780
3599 3640
2378 2414
Placebo Clopidogrel
6203 6259
The CURE Investigators. N Engl J Med
2001345494-502
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ABSOLUTE RISK REDN. CHD death and nfMI
20 15 10 5
4S
X

Abs. Redn. CHD death nfMI (Intervention) (Events
per 1000 persons years)
HPS
CARE
X
LIPID
X
X___
WOSCOPS
X
AFCAPS
X
PROSPER
X
Possibly multiple events
X
ASCOT-LLA
ALLHAT-LLT
X
10
20
30
40
50
Control CHD deaths and nfMI (Events per 1000
person years)
(A. Tonkin, unpublished)
Lipids
11
HPS Vascular Events by LDL-C
Risk ratio and 95 CI
STATIN (10269)
PLACEBO (10267)
Baseline LDL
STATIN better
STATIN worse
LDL mg/dl (mmol/L)
lt 100 ((2.6)
285
360
³
100 lt 130
670
881
³
130 (3.4)
1087
1365
ALL PATIENTS
2042
2606
(19.9)
(25.4)
0.4
0.6
0.8
1.0
1.2
1.4
Simvastatin 40mg in pts with vasc. dis. or
diabetes
Lancet 2002
HPS
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WIDENING INDICATIONS

• Beta-blockers
• Post-MI (CHD) ? CHF
• ACE inhibitors
• CHF ? CHD

Sec. Prevention
13
POST-AMI BETA-BLOCKERS
Post-AMI follow-up extended to 3 years (Swedish
Timolol Study)
BB
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ACE Inhibitors CVD Risk
Trial LV status No. of MIs/no. of
patients Relative risk p reduction
ACE inhibitor Placebo (95 CI)
SOLVD EF lt 0.35 127/1285 158/1284 23 (2-39)
0.02 (treatment) with CHF (9.9) (12.3)
SOLVD EF lt 0.35 161/2111 204/2117 24 (6-38)
0.01 (prevention) without (7.6) (9.1) CHF
SAVE EF lt 0.4 133/1115 170/1116 24 (5-40)
0.02 (11.9) (15.2)
Total 421/4511 532/4517 23 (12-33)
0.0002 (9.3) (11.8)
Lonn E et al. Circulation 1994902056-2069.
CHF
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ACEI IN CHD
1 NEJM 2002342145-53 2 Lancet
20013581033-41 3 Lancet 2003362782-8 4
NEJM 20043512058-68
Sec. Prevention
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EUROPA PRIMARY ENDPOINT
CV death, MI or cardiac arrest
RRR 20 95 CI 9 - 29
No events
Lancet 2003 362 782-88
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PHARMACOLOGICAL MANAGEMENT

• Antiplatelet agents
• Aspirin
• Clopidogrel
• ACE Inhibitors
• All post AMIs, start early
• Beta-blockers
• All post ACS, unless CI
• BB for CHF (carvedilol, bisoprolol, metoprolol)
• Statins
• All patients with CHD
• Anticoagulants
• Warfarin - at risk of TE
• Warfarin and aspirin (monitor)

NHF 2004
18
BIOMEDICAL RISK FACTORS/MEDICAL MANAGEMENTGOALS
TARGETS

• Lipids
• LDL lt 2.0
• Triglycerides lt 1.5
• Blood Pressure
• Dx 140/90 on several occasions (note white coat
  effect)
• Targets Dependent on age and presence of
  diabetes and proteinuria
• Diabetes
• Identify undiagnosed T2D
• Optimise BSL (HbA1c lt7mm/l)

NHF 2004
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COACH PROGRAM DISCHARGE MEDICATIONS CHD PATIENTS
(1.1.03 2.12.04)
St. Vincents Hosp, Melb Austin Health
Melbourne Health Alfred Hosp. Melb. Div. of
General Practice (MDGP) - In GP, high risk
patients
Sec. Prev.
M. Vale (personal communication)
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UK NATIONAL SERVICE FRAMEWORK FOR CHD
By April 2002, to improve the use of effective
medicines after heart attack (especially use of
aspirin, beta-blockers and statins) so that
80-90 of people discharged from hospital
following a heart attack will be prescribed these
drugs.
Sec Prevention
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CHD A WORKING DEFINITION

• Myocardial infarction
• Angina Pectoris
• Unstable Angina
• Stable angina
• Revascularisation as evidenced by
• Angioplasty /- stent
• Coronary artery bypass surgery