Cardiovascular%20Epidemiology.%20Part%20II

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Lifetime Risk of Coronary Heart Disease in the
Framingham Study
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• Men Women

At age 40 years 48.6 31.7 At age 70
years 34.9 24.2 Lloyd-Jones et al. Lancet
1999 35389-92
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First Coronary Events Framingham Study
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• Percent as Specified Event
• Myocardial Angina Sudden
• Infarction Pectoris Death
• Age Men Women Men Women Men Women
• 35-64 43 28 41 59
  9 4
• 65-84 55 44 28 41
  11 7.4
• Framingham Study 44 year follow-up.

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Estimated 10-Year CHD Risk in 55-Year-Old Adults
According to Levels of Various Risk Factors
Framingham Heart Study
A B C D Blood
Pressure (mm Hg) 120/80 140/90 140/90 140/90 Total
Cholesterol (mg/dL) 200 240 240 240 HDL
Cholesterol (mg/dL) 50 50 40
40 Diabetes No No Yes
Yes Cigarettes No No No
Yes
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Estimated 10-Year Stroke Risk in 55-Year-Old
Adults According to Levels of Various Risk
Factors Framingham Heart Study
A B C D E F Systolic BP 95-105 130-148 130-148
130-148 130-148 130-148 Diabetes No No Yes Yes Yes
Yes Cigarettes No No No Yes Yes Yes Prior Atrial
Fib. No No No No Yes Yes Prior
CVD No No No No No Yes
BP in millimeters of mercury (mmHg)
Source Stroke 199122312-318.
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A B C D E F Systolic BP 95-105 130-148 130-148
130-148 130-148 130-148 Diabetes No No Yes Yes Yes
Yes Cigarettes No No No Yes Yes Yes Prior Atrial
Fib. No No No No Yes Yes Prior
CVD No No No No No Yes
BP in millimeters of mercury (mmHg)
Estimated 10-year stroke risk in 55-year-old
adults according to levels of various risk
factors (FHS). Source Wolf et al.,
Stroke.199122312-318.
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Offspring CVD Risk by Parental CVD Status
Framingham Study
Parental CVD lt55 men, lt65 Women
Risk Ratio
2.5
2
2.2
1.5
1.7
1.7
1.7
1
1.0
1.0
0.5
0
Men
Women
Adjusted for age, total/HDL Chol. ratio, SBP,
smoking, diabetes, BMI
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Risk imposed by a strong family history of heart
attacks varies widely depending on the burden of
modifiable risk factors
Multivariable Risk
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Doubts about cholesterol as late as 1989
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Risk of Coronary Heart Diseaseby Serum
Cholesterol
30-Year Follow-up, The Framingham Study
Age-Adjusted Annual Rate per 1000
Serum Cholesterol Age 35-64 Age 35-64 Age 65-94 Age 65-94
Serum Cholesterol Men Women Men Women
84-204 8 4 22 11
205-234 13 5 24 15
235-264 14 4 26 17
265-294 15 7 23 17
295-1124 26 10 38 32
Trends Significant at P?.001. P?.07.
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Correlation Between Serum
Cholesterol and CVD Mortality
Multiple Risk Factor Intervention Trial (MRFIT)
N325,346
30
Untreated Patients
25
55-57 years
50-54 years
20
15
6-Year CVD Death Rate Per 1000
45-49 years
10
40-44 years
35-39 years
5
0
Q1 (lt182)
Q2 (182-202)
Q3 (203-220)
Q4 (221-244)
Q5 (gt244)
Serum Cholesterol Quintile (mg/dL)
Q serum cholesterol quintile. Kannel WB et al.
Am Heart J. 1986112825-836.
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Lifetime Risk of CHD Increases with
Serum Cholesterol
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Cholesterol
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44
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Framingham Study Subjects age 40 years DM
Lloyd-Jones et al Arch Intern Med 2003 1966-1972
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Age-adjusted prevalence of Adults age 20 and
older with LDL cholesterol of 130 mg/dL or
higher, by race/ethnicity and sex (NHANES
2003-2004). Source NCHS and NHLBI. NH
non-Hispanic.
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Age-adjusted prevalence of Adults age 20 and
older with HDL cholesterol lt40 mg/dL, by
race/ethnicity and sex (NHANES 2003-2004).
Source NCHS and NHLBI.
NH non-Hispanic.
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Trends in mean total serum cholesterol among
adults age 20 and older, by race/ethnicity, sex
and survey (NHANES 1988-94, 1999-02 and
2003-04). Source NCHS and NHLBI. NH
non-Hispanic.
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Trends in mean total blood cholesterol among
adolescents ages 12-17 by race, sex, and survey
(NHES 1966-70 NHANES 1971-74 and 1988-94).
Source NCHS and NHLBI.
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CK Friedberg on Hypertension Diseases of the
Heart 1996
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• There is a lack of correlation in most cases
  between the severity and duration of hypertension
  and development of cardiac complications.

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Relation of Non-Hypertensive Blood Pressure to
Cardiovascular DiseaseVasan R, et al. N Engl J
Med 2001 3451291-1297
10-year Age- Adjusted Cumulative Incidence
Hazard Ratio SBP Women Men lt120/80 1.0
1.0 120-129 1.5 1.3 130-139
2.5 1.6 H.R. adjusted for age, BMI,
Cholesterol, Diabetes and smoking Plt.001
10.1
7.6
5.8
4.4
2.8
1.9
Framingham Study Subjects Ages 35-90 yrs.
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Prevalence of high blood pressure in Adults by
age and sex (NHANES 1999-2004). Source NCHS and
NHLBI.
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Extent of awareness, treatment and control of
high blood pressure by age (NHANES 1999-2004.)
Source NCHS and NHLBI.
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Age-adjusted prevalence trends for high blood
pressure in Adults age 20 and older by
race/ethnicity, sex and survey (NHANES 1988-94
and 1999-2004). Source NCHS and NHLBI.
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Extent of Awareness, Treatment and Control of
High Blood Pressure by Race/Ethnicity (NHANES
1999-2004). Source NCHS and NHLBI.
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CK Friedberg on HypertensionDiseases of the
Heart 1966
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• Hypertension imposes a load on the heart which
  for many years may be compensated by left
  ventricular hypertrophy

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CVD Risk Imposed by ECG-LVH Framingham Study
36-yr. Follow-up
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• Age-adjusted Risk Excess
  Risk
• Rate per 1000 Ratio
  per 1000
• Age Men Women Men Women Men Women
• 35-64 164 135 4.7 7.4
  129 117
• 65-94 234 235 2.8 4.1
  51 178
• Biennial Rate per 1000. CVDCHD, stroke,
  peripheral vascular disease, heart
  failure Plt0.001

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Smoking Statement Issued in 1956 by American
Heart Association
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• It is the belief of the committee that much
  greater knowledge is needed before any
  conclusions can be drawn concerning relationships
  between smoking and death rates from coronary
  heart disease. The acquisition of such knowledge
  may well require the use of techniques and
  research methods that have not hitherto been
  applied to this problem.
• Circulation 1960 vol. 23

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CHD Risk by Cigarette Smoking. Filter Vs.
Non-filter. Framingham Study. Men lt55 Yrs.
14-yr. Rate/1000
210
206
210
119
112
59
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Prevalence of current smoking for Adults age 18
and older by race/ethnicity and sex
(NHIS2004). Source MMWR. 2004541121-24. NH
non-Hispanic.
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Prevalence of high school students in grades 9-12
reporting current cigarette smoking by
race/ethnicity and sex. (YRBS2005).
Source
MMWR. 200655SS-5. June 9, 2006. . NH
non-Hispanic.
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Diseases of The HeartCharles K Friedberg MD, WB
Saunders Co. Philadelphia, 1949
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• The proper control of diabetes is obviously
  desirable even though there is uncertainty as to
  whether coronary atherosclerosis is more frequent
  or severe in the uncontrolled diabetic

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Risk of Cardiovascular Events in Diabetics
Framingham Study
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• Age-adjusted
• Biennial Rate Age-adjusted
• Per 1000 Risk Ratio
• Cardiovascular Event Men Women Men
  Women
• Coronary Disease 39 21 1.5
  2.2
• Stroke 15 6 2.9 2.6
• Peripheral Artery Dis. 18 18 3.4
  6.4
• Cardiac Failure 23 21 4.4
  7.8
• All CVD Events 76 65
  2.2 3.7
• Subjects 35-64 36-year Follow-up
  Plt.001,Plt.0001

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Age-adjusted prevalence of physician-diagnosed
diabetes in Adults age 18 and older by
race/ethnicity and sex (NHANES 1999-2004).
Source
NCHS and NHLBI. NH non-Hispanic.
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Mortality rates in U.S. adults, age 30-75, with
metabolic syndrome (MetS), with and without
diabetes mellitus (DM) and pre-existing CVD
(NHANES II 1976-80 Follow-up Study).
Source Malik et al., Circulation.
20041101245-50. Average of 13 years of
follow-up.
Note Age and gender adjusted.
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Skepticism About Importance of Obesity
Keys A, Aravanis C, Blackburn H, et al. Ann
Intern Med 1972 7715-27. Concluded that all
the excess risk of coronary heart disease in the
obese derives from its atherogenic
accompaniments, illogically leaving the
impression that obesity is therefore
unimportant. Mann GV. N Engl J Med 1974
291226-232. The contribution of obesity to CHD
is either small or non-existent. It cannot be
expected that treating obesity is either logical
or a promising approach to the management of
CHD. Barrett-Connor EL. Ann Intern Med 1985
1031010-1019 NIH consensus panel is equivocal
about the role of obesity as a cause of CHD.
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Relation of Weight Change to Changes in
Atherogenic Traits The Framingham Study
Frantz Ashley, Jr. and William B Kannel J Chronic
Dis 1974 Weight gain is accompanied by
atherogenic alterations in blood lipids, blood
pressure, uric acid and carbohydrate
tolerance. It seems reasonable to expect that
correction of overweight will improve the
coronary risk problem. Avoidance of overweight
would seem a desirable goal in the general
population if the appalling annual toll from
disease is to be substantially reduced.
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Risk Factor Sum and Obesity
Framingham Study
(1971-74) and (1989-93)
3
2.4
Risk factors accumulate with weight gain
1.8
Risk Factor Sum
1.2
0.6
0
Q1 Q2 Q3 Q4 Q5 Overall
Thin
Obese
Risk variables include bottom quintile for HDL-C
and top quintiles for cholesterol, SBP,
triglycerides and glucose
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Age-adjusted prevalence of obesity in Adults ages
20-74 by sex and survey (NHES, 1960-62 NHANES,
1971-74, 1976-80, 1988-94 and 2001-2004).
Source Health, United States, 2006, unpublished
data. NCHS.
Note Obesity is defined as a BMI of 30.0 or
higher.
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Trends in prevalence of overweight among U.S.
children and adolescents by age and survey
(NHANES, 1971-74, 1976-80, 1988-94 and
2001-2004). Source Health, United States, 2006,
unpublished data. NCHS.
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Prevalence of overweight among students in grades
9-12 by race/ethnicity and sex (YRBS 2005).
Source BMI 95th percentile or higher. MMWR. 2006
55 No. SS-5. NH non-Hispanic.
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Prevalence of leisure-time physical inactivity
among adults age 18 and older by race/ethnicity,
and sex. (BRFSS 1994 and 2004). Source MMWR,
200554No. 39. NH non-Hispanic.
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Note Currently recommended levels is defined
as activity that increased their heart rate and
made them breathe hard some of the time for a
total of at least 60 minutes/day on 5 or more of
the 7 days preceding the survey.
Prevalence of students in grades 9-12 who met
currently recommended levels of physical activity
during the past 7 days by race/ethnicity and sex
(YRBS 2005). Source MMWR. 200655No. SS-5. NH
non-Hispanic.