New Trends in Heart Disease

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New Trends in Heart Disease

• Prof Chu-Pak Lau
• Cardiology Division
• University of Hong Kong
• Queen Mary Hospital

Public Health Conference 6 March 2004
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Global Burden of CVS diseaseBonow RO et al Circ
2002 1061602-1605

• CVS death toll
• 14.7M in 1990 to 17M 1999
• Main burden due to CAD, is the leading cause of
  death worldwide (30). CVA second leading cause
• WHO 1 Billion people overweight
• 18M children lt5 are overweight
• 60 of the world population is physically
  inactive
• DM 150M people, will double in 2025
• Tobacco consumption still increasing

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• Coronary Artery Disease
• Heart Failure
• Atrial Fibrillation

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CVS Death per 100,00 population AHA Heart
Stroke Statistics 1999
Men
Women
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CAD mortality in Asian-Pacific(Men /100,000)
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CAD mortality in Asian-Pacific(Women /100,000)
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Sino-MONICA Project.Circulation 2001
103462-468(1)

• 7 Year project (1987-1993)
• WHO project
• Collaboration with BIHLBD

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Sino-MONICA Project.Circulation 2001
103462-468(2)

• Incidence and mortality of CVS disease is low but
  those of CVA were high
• Great disparity in incidence
• CVS 108.7/100,000 to 3.3/100,000 for men
• CVA 553.3/100,000 to 33/100,000
• 3. Geographical difference
• North gt South
• e.g. Beijing 70.3 vs Guangdong 59.7/100,000

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Leading Cause of Death in HK (2000)
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Leading Causes of Death in US and HK (Female)
Year 2000
Per 100,000 population
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Special Features of Heart Disease of Women

• Older
• Delayed presentation
• Higher mortality rate
• Triple vessel disease and smaller vessel size
• Higher CABG risk
• Suboptimal response to PTCA
• Despite a lower CAD risk, HK women have mortality
  from strokes comparable to the US

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Modifiable Risk Factors

• Hypertension
• Hypercholesterolemia
• Diabetes mellitus
• Homocysteine
• C-Reactive Protein
• Exercise
• Obesity
• Cigarette smoking

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BP, Cholesterol and Stroke in Eastern Asia
Eastern Stroke and Coronary Heart Disease
Collaborative Research Group Lancet 1998 352
1801-1807
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Serum Cholesterol in Urban Cities of Asia
Mg/dl
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Global Prevalence of Diabetes
1997 2010
124 million (2.1) 221 million
53 in Asia 61 in Asia
(Amas, McCarthy Zimmet Diabetic Med, 1997) (Amas, McCarthy Zimmet Diabetic Med, 1997)
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Prevalence of Diabetes and IGT China
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Obesity
Prevalence in the US in American white (1999-2000)
Adults Adults Children 6-11 years Children 6-11 years Adolescents 12-19 years Adolescents 12-19 years
Male Female Male Female Male Female
27.3 30.1 12.0 11.6 12.8 12.4
Obesity BMI gt 30
CDC 1999-2000
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Mortality from CAD in HK (Dept of Health Annual
Report 1997-2001) (1)
No. of Pts
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Mortality from CAD in HK (lt45yrs)(Dept of Health
Annual Report 1997-2001) (2)
of Heath Disease lt45 years

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The Role of Platelets in Inflammation and Plaque
Stability
Activated platelets
Inflammatory modulators
CD40L Platelet-derived growth factor Platelet
factor 4 RANTES Thrombospondin Transforming
growth factor-? Nitric Oxide
Plaque rupture thrombosis
Libby P. Circulation 20011031718-1720
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Novel Risk Factors as Predictors of Peripheral
Arterial Disease
Relative Risk of Incident Peripheral
Arterial Disease (Adjusted for age, smoking, DM,
HTN, family history, exercise level, and BMI)
Ridker et al. JAMA 20012852481-2485
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AHA/CDC Recommendations for Clinical and Public
Health Practice
Clinical Practice

• Measurement of hs-CRP is an independent marker of
  risk and, in those judged at intermediate risk by
  global risk assessment (10-20 CHD/10 yr) may
  help direct further evaluation therapy in
  primary prevention of CHD. The benefits of such
  therapy based on this strategy remain uncertain.
  (Class IIa, Level of Evidence B)
• Measurement of hs-CRP may be used at discretion
  of the physician as part of global risk
  assessment in adults without known CVD. The
  benefits of such therapy based on this strategy
  remain uncertain. (Class IIb, Level of Evidence
  C)

AHA/CDC Statement. Circulation 2003 107499511
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Hong Kong Cardiovascular Risk Factor Prevalence
Study-2 (CRISPS2)

• Bernard Cheung
• Department of Medicine
• University of Hong Kong

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Percentage prevalence of diabetes
Age Age lt35 35-44 45-54 55-64 65-74 gt74
1995-6 Male 2.0 5.8 7.5 18.6 21.7 --
1995-6 Female 1.4 3.2 10.9 21.2 29.3 --
2001-2 Male 2.8 9.2 8.8 23.0 34.5 30.0
2001-2 Female 3.4 4.8 6.0 29.8 33.3 43.5
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Weight

• Body weight increased by 0.540.14 kg (plt0.001)
• There was no significant change in body mass
  index (BMI)
• Waist circumference increased from 78.30.3 to
  80.50.3 cm (plt0.001)

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Prevalence of overweight and obesity in the study
population
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BMI?25 is associated with diabetes (OR 3.1
2.0-4.7) and hypertension (OR 3.5 2.5-5.0)
Overweight, diabetes and hypertension
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Conclusions

• In the CRIPS2 cohort, hypertension (27),
  diabetes (15), hypercholesterolaemia (46) and
  overweight (35) are common
• As these risk factors can be modified by diet and
  lifestyle, the prevention of cardiovascular
  disease requires a community approach

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• Coronary Artery Disease
• Heart Failure
• Atrial Fibrillation

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Heart Failure How Big is the Problem Really?

• 4,790,000 Americans have heart failure
• Based on extrapolation of NHANES data
• 550,000 new cases each year
• Based on extrapolation of 44-year Framingham data
• HF contributed to 287,200 deaths in 1999
• Primary cause in 54,913
• HF deaths have increased by 145 in 20years
• Age-adjusted rates have not changed
• Mortality rates may be declining
• Hospital discharges increased from 377,000 to
  962,000 between 1979 and 1999
• Age adjusted rates and length of stay are
  declining

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45-64
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A New Epidemiology of Ventricular Dysfunction

• The Old Epidemiology of CHF
• Included only symptomatic LV failure
• Often excluded persons gt 75 years old
• Did not characterize ventricular function
• The New Epidemiology of Ventricular Dysfunction
  
• Includes assessment of ventricular structure and
  systolic / diastolic function
• No age limits

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Community Echo Survey of Systolic and Diastolic
LV DysfunctionRedfield MM et al, JAMA 2003 289
194-202

• Pts Methods
• 1997-2000 2042 subjects of Olmsted County were
  screened with echo and Doppler, and followed for
  5yrs
• Results
• CHF 2.2
• Systolic Dysfunction 6
• EF gt 50 44
• Diastolic Dysfu Mild 20.6
• Mod 6.6
• Severe 0.7

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Pharmacotherapy

• ACEI
• Angiotensin II blockers
• Betablockers
• Aldosterone antagonist
• Newer agents

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Declining Mortality in Heart Failure Trial
Severe
Mild-Mod
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Prevalence of Heart Failure with Preserved EF
EFgt 45
EFgt 50 N269
EFgt 45 N338
EFgt 40 N782
EFgt 50 N73
EFgt 50 N137
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Main Problems of Electrical Alterations

• 1. PR prolongation (improper LV filling)
• 2. Interventricular asynchrony (RV-LV asynchrony)
• 3. Intraventricular asynchrony (regional LV
  asynchrony)
• Results in
• 1. ? Stroke volume
• 2. ? Contractility
• 3. MR

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Before
After
CRT or Reverse Remodelling ?
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CRT Trials
6m HW (m)
Echo (LVED in mm)
LVEF ()
Significant Improvement
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COMPANION Death or HF Hospitalization( of
composite Endpoints)
Bristow MR ACC 2003
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• Coronary Artery Disease
• Heart Failure
• Atrial Fibrillation

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AF Incidence/resource implication

• In USA
• 2 million 160,000 new cases/yr
• 3-5 population gt60yr
• 1.5 million primary reasons for consultation
• 1.4 million hospital discharges
• 130,000 AE visits
• 6.6 billion US Medicare

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Prevalence of AF in ElderlyRyder Benjamin AJC
1999
()
Countries Age (yrs)
USA (70-80)
Netherlands (70-80)
UK (70-80)
Hong Kong (60-94)
Japan (gt40)
Himalaya (gt15)
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AF and Mortality Framingham Heart
StudyBenjamin et al Circulation 1998 98946-952
Methods 5209 subjects, age 55-94, follow-up
for 40yrs. AF documented by biennial ECG Result
AF increases mortality by 50 in men and 100
women Conclusion Maintenance of sinus rhythm
may decrease mortality
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Prevalence of AF in Heart Failure Trials
Study NYHC Prevalence,
SOLVD Prevention SOLVD Treatment V-HeFT CHF-STAT DIAMOND-CHF GESICA CONSENSUS I II-IV II-III II-III III-IV III-IV IV 4.2 10.1 14.4 15.4 25.8 28.9 49.8
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AF
HF
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AT/AF Affect Survival ?
Mortality ()
MiddleKauff1
Framingham2
SOLVD3
DIG4
VA-CHF5

1. Middlekauff HR et al Circulation 1991 8440-48
2. Benjamin EJ et al Circulation 1998 98946-952
3. Dries DL et al JACC 1998 32 695-703
4. Mathew J et al Chest 2000 118 914-922
5. Carlson PE et al Circulation 1993 87 (supple)
   VI 102-110

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Emergence of New Epidemics of CVS Disease

• Two new epidemics of cardiovascular disease are
  emerging heart failure and atrial fibrillation

E. Braunwald
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Therapeutic Strategies in AF
Maintain SR
Rate Control
vs

• Necessary for all therapy
• Minimal S/E
• Symptomatic benefit
• EF
• ? ET

• Theoretically sound
• After restoring SR
• EF
• ET
• atrial function
• ? ? stroke

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AFFIRM Study N Engl J Med Dec 2002 347 1825
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Strategies for AF Management in CHF

• Drug
• Ablate pace
• Pulmonary vein ablation
• Atrial defibrillators
• Main cause of AF is HT

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Global Approach to Reduce CVS/CVA Death

• International cooperation
• Research and Education
• Targeted primary prevention strategies
• e.g. tobacco use, hypertension control,
  affordable clinical algorithm
• Advocacy e.g. World Heart Day
• Availability of cost-effective meds

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The Hong Kong AMI Registry 1995-1996 Woo KS et al
for the HK-AMI Task Force

• Background
• A territory wide survey of all cases of AMI
  admitted into hospital. Initiated by the HK
  College of Cardiology
• Subject and Methods
• A total of 3334 AMI (diagnosis by symptom, ECG
  and enzyme) were prospectively entered into a
  centralized data base, and uniformity and
  accuracy of data were audited by a research
  coordinator. In-hospital mortality complication
  were examined 96.2 were ethnically Chinese

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Demographics of AMI in HK (95-96)
Sex
Age
()
Female 72.9 yrs
Sex Age
Male 64.8 yrs
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AMI Incidence Mortality in US
(1975-1995)Goldberg RJ Et al Circulation 1999
33 1533-1539
Mortality ()
Incidence /100,000
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