epidemiology of cerebro vascular diseases

1. EPIDEMIOLOGY OF CVD
Mr. Mahesh Chand
Lecturer
M.Sc. Nursing

2. OBJECTIVES
• 10th causes of death worldwide
• IHD death statistics
• According to UN reports numbers of of deaths
due to cvd in the year
• To know rising prevalence
• According NCHS
• Trends in various age group
• Pathogenesis CVD
• Facts CVD in India

3. Cont….
• Levels of prevention
• Risk factors in primary prevention
• Benefit of secondary prevention
• National program for prevention and control
of diabetes cvd and stroke
• Complementary alternative system (CAM)

4. Top 10 causes of death worldwide

5. Ischemic Heart Disease Death Statistics

7. Rising prevalence
Source : Report of the Registrar General of India.
National Commission on Macroeconomics and Health (NCMH) Background Papers 1996.

8. Largest share in non communicable
diseases
Source : National Council of Health Science data India 2005.

9. Trend in various age groups
Source : National Commission on Macroeconomics and Health (NCMH)
background papers , Sept 2005.

10. Pathogenesis of CVD
• Ischemic heart disease occurs when flow of
oxygen rich blood to the myocardium is
blocked.
• Atherosclerosis is commonest cause.

11. Image from: www.nhlbi.nih.gov/health/health-topics/topics/heartattack

12. Facts about CVD In India
• Public health estimate indicate –
– 60% of the world’s CVD burden.
– Involves relatively younger age.
– Smaller coronary arteries : High incidence of CVD.
– Diffuse distal disease
– Multi vessel disease
– High incidence in women.
High Mortality rate

13. Primary and Secondary Prevention
• Primary prevention : Prevention of onset of disease
in persons without symptoms.
• Primordial prevention : Prevention of risk factors
causative of the disease, thereby reducing the
likelihood of development of the disease.
• Secondary prevention : Prevention of death or
recurrence of disease in those who are already
symptomatic.

14. Risk Factors in Primary Prevention
• Non modifiable risk factors :
– Age.
– Gender.
– Race.
– Family history of CVD.
• Behavioral risk factors :
– Sedentary lifestyle.
– Unhealthy diet.
– Heavy alcohol or cigarette consumption.
• Physiological risk factors :
– Hypertension.
– Obesity.
– Hyperlipidemia.
– Diabetes.
Modifiable risk factors

15. Population & community wide risk reduction approach
• Populations with high rates of CVD :
– Western lifestyle.
– High-fat diet.
– Physical inactivity.
– Tobacco use.
• Requires public health services :
– Surveillance.
– Education.
– Organizational partnerships.
– Legislation/policy.
•Activities in a variety of community settings:
– Schools.
– Worksites.
– Healthcare facilities.
– Community worship places.
Targets of a population-
wide approach

16. Individual and High-Risk Approaches
• Primary Prevention Guidelines (1995) and Secondary
Prevention Guidelines (Revised 2001) released by the
American Heart Association provide advice regarding
risk factor assessment, lifestyle modification, and
pharmacologic interventions for specific risk factors.
• Barriers exist in the community and healthcare setting
that prevent efficient risk reduction.
• Surveys of CVD prevention-related services show
disappointing results regarding cholesterol reduction
therapy, smoking cessation etc.

17. Individual Risk Assessment
Careful assessment of medical history, physical
examination, laboratory examinations.
– Tobacco, diet, and physical activity history.
– Blood pressure, height/weight, waist/hip
circumference, BMI, lipid profile.
– Determination of global risk score.

18. Framingham Risk Algorithms
• Provides 10-year estimated risk of CHD :
Applicable to specific ages and persons.
• Different versions published: –
– Wilson 1998 version includes LDL-C (Age limit 30-74).
– NCEP III 2001 version :- Wider age range but does not
include diabetes.
– D’Agastino 2001 version includes diabetes. Applicable to
other ethnic groups.
NCEP : National Cholesterol Education Programme

19. Considerations for Secondary Prevention
• Framingham algorithms can be used for
prediction of recurrent CHD events over next 2
years.
• Important predictors of reinfarction /CHD death
over 10-years post-MI (Wong et al. 1989).
– Blood Pressure.
– Total cholesterol.
– Diabetes.

20. Secondary Prevention Strategies of
Proven Benefit
• AHA Secondary Prevention Statement outlines
recommended assessment, management, and
risk factor goal levels.
• Proven strategies include: –
– Cholesterol-lowering therapy.
– Blood pressure reduction.
– Antiplatelet therapy.
– Smoking cessation.
– Dietary therapy.
– Exercise.
AHA : American Heart Association

22. Tobacco quitting
• Number one preventable risk factor
• Health benefits of quitting smoking begin immediately
– Most effective is combined pharmacologic and behavioral
strategies
• Governmental prevention programs including package health
warning labels and graphics.

23. Dietary Strategies
 Home cooked meals.
 Preferred versus restaurant and fast food.
 Carbohydrates.
 Recommend whole grains, barley, oats
 Roti is healthier option versus processed white rice.
 Proteins – Veg preferred.
 Veg Options include Soy, Tofu.
 White meats preferred over red meats.
 Fat - Prefer unsaturated fats like EPA/DHA & Alpha-Linoleic Acid.
 Nuts and fresh fish are excellent sources
 Avoid saturated fats such as ghee, margarine, coconut oils
 Don’t reuse cooking oil-this is unfortunately a common practice in India.

24. Cholesterol goals
• Diet and exercise are key!
• Total cholesterol goal: <200 mg/dL
• LDL (bad cholesterol) goal: <100 mg/dL
• Triglycerides Goal: <150 mg/dL
• HDL (good cholesterol) goal:
– >40 mg/dL in men, >50 mg/dL for women
National Heart Lung and Blood Institute: www.nhlbi.nih.gov/guidelines/cholesterol/index.htm

25. Exercise
• 30 minutes of moderate activity most days of
week.
– Helps lower BP.
– Diabetes.
– Raises good cholesterol (HDL).
– Manages stress.
– Improves bone health.
– Helps control weight.

26. Blood Pressure
• Quick screening recommended during all
healthcare visits .
• Controlling hypertension reduces risk of heart
disease by 25%
– Strategies include weight loss (i.e. via weight loss,
exercise, diet), low sodium in diet, limit alcohol
• Goal BP: <120 systolic and <80 diastolic
pressures
American Heart Association website: www.americanheart.org

27. Diabetes
• Optimal fasting blood sugar is< 100 mg/dL
• Criteria for Diagnosis of Diabetes -
– Fasting glucose 126 mg/dL or higher
– Random glucose of 200 mg/dL or higher + symptoms
• Goal to detect patients at level of impaired fasting
glucose of 100-125 mg/dL
• Individuals at risk of developing the disease can
prevent it by modest diet and exercise plan.
American Diabetes Association website: www.diabetes.org

29. National Programme for Prevention and Control
of Diabetes, Cardiovascular Disease and Stroke
• The evidence-based recommendations given in these
guidelines provide guidance on specific preventive actions to
initiate, and with what degree of intensity.
• The accompanying World Health Organization/ International
Society of Hypertension (WHO/ISH) risk prediction charts
enable the estimation of total cardiovascular risk .

30. National Programme for Prevention and Control
of Diabetes, Cardiovascular Disease and Stroke
• Settings –
Primary care and other levels of care including low resource settings.
• Resource Needs -
• Human resources: Medical doctors and health workers.
• Equipment:
– Stethoscope.
– Blood pressure measurement device.
– Measuring tape.
– Weighing machine.
– Equipment for testing urine glucose and urine albumin.
– Assay of blood glucose and lipid profile.
–
• Drugs:
– Thiazide diuretics.
– Beta blocker.
– Angiotensin converting enzyme inhibitors.
– Calcium channel blockers.
– Aspirin.
– Metformin, Glibenclamide, Insulin.
– Statins.

31. 10 year risk of cardiovascular event Risk classification Intervention
Risk <10% Low risk
Encourage for lifestyle modification
(promote healthy diet, physical activity,
say no to tobacco and alcohol) Risk
assessed after 5 years unless significant
change in health status. Refer to
medical doctors for evaluation and
management
Risk 10% to <20% Moderate risk
Monitor risk profile every 2 years.
Encourage for lifestyle modification
(promote healthy diet, physical activity,
say no to tobacco and alcohol) Refer to
medical doctors for evaluation and
management
Risk 20% to <30% High risk
Monitor risk profile yearly. Encourage
for lifestyle modification (promote
healthy diet, physical activity, say no to
tobacco and alcohol) Refer to medical
doctors for evaluation and
management
Risk ≥30% Very High risk
Individuals in this category are at very
high risk of fatal or non-fatal vascular
events Monitor risk profile every 3–6
months Encourage for lifestyle
modification (promote healthy diet,
physical activity, say no to tobacco and
alcohol) Refer to medical doctors for
evaluation and management

32. Complementary and Alternative
Medicine (CAM)
• Biologically-based therapies.
• Mind-body therapies.
• Manipulative and body-based therapies.
• Whole medical systems.
• Energy medicine.

33. Biologically-Based Therapies
• Aromatherapy.
• Chelation therapy.
• Diet-based therapies.
• Folk medicine.
• Iridology.
• Megavitamin therapy.
• Neural therapy.
• Phytotherapy /herbal medicine.

34. Mind-Body Therapies (MBT)
• Anthroposophical medicine.
• Autogenic training.
• Biofeedback.
• Bio resonance.
• Cognitive-behavioral therapies.
• Deep-breathing exercises.
• Group support.
• Hypnosis.
• Imagery.
• Meditation.
• Prayer & relaxation.

35. Manipulative and Body-Based
Therapies
• Acupressure.
• Alexander technique.
• Bowen technique.
• Chiropractic manipulation.
• Feldenkrais method.
• Massage.
• Osteopathic manipulation.
• Reflexology.
• Rolfing.
• Trager bodywork.

36. Whole Medical Systems
• Acupuncture.
• Ayurveda.
• Homeopathy.
• Naturopathy.

37. Energy Medicine
• Healing touch.
• Light therapy.
• Magnetic therapy.
• Millimeter wave therapy.
• Qigong.
• Reiki.
• Sound energy therapy.

38. Summary Guidelines