Decreasing Risk of Developing Cardiovascular Disease

1
(No Transcript)
2
Decreasing Risk of Developing Cardiovascular
Disease
Jill Birnbaum, State Advocacy Consultant,
National Center, American Heart Association
3
(No Transcript)
4
Risk Factors

• Tobacco
• High Blood Pressure
• High Cholesterol
• Physical Inactivity
• Overweight and Obesity
• Diabetes
• Nutrition
• Metabolic Syndrome

5
Preventing Cardiovascular Disease Risk

• Primary Prevention
• Individual
• Environmental
• Secondary Prevention
• Heart disease and stroke are disorders with
  complex etiologies and multiple risk factors, so
  a multifaceted approach to their prevention is
  crucial to success.

6
Policy and Environmental Change

• We need to create policy and environmental
  changes that will support behavior change and
  risk factor prevention and control.
• To support behavior change, risk factor control,
  and uniform access to high quality health care,
  heart disease and stroke prevention programs must
  address policy, environmental, and systems-level
  changes in multiple settings.

7
Preventing Cardiovascular Disease Risk

• In direct contrast with conventional thinking,
  80 to 90 of patients with coronary heart
  disease have at lease one conventional risk
  factor
• Although research on nontraditional risk factors
  and genetic causes of heart disease is important,
  clinical medicine, public health policies, and
  research efforts must place significant emphasis
  on the four conventional risk factors and the
  lifestyle behaviors causing them to reduce the
  epidemic of coronary heart disease.

8
Trends in Cardiovascular Risk Factors in
the U.S. Population Aged 20-74 NHES 1960-62,
NHANES1971-75 to 1999-2000
Source JAMA 2005. 293 1868-74.


9
Tobacco

• Mortality
• From 19972001, an estimated 437,902 Americans
  died each year of smoking-related illnesses
• 34.7 percent of these deaths were
  cardiovascular-related.
• Cigarette smoking results in a two-to-three-fold
  risk of dying from CHD.
• An estimated 35,052 nonsmokers die from CHD each
  year as a result of exposure to environmental
  tobacco smoke.

10
Tobacco

• Primary prevention goal
• Complete cessation
• No exposure to secondhand smoke

11
Tobacco

• Prevention
• Individual
• Stop smoking
• Eliminate exposure to secondhand smoke
• Environmental Change
• Increasing the price of cigarettes through
  tobacco tax increases
• Establish smokefree workplace laws
• Support tobacco control prevention and treatment
  programs

12
Tobacco

• The impact to CVD in the first year of making all
  workplaces smoke free
• 1540 myocardial infarctions and 360 strokes would
  be averted
• Health care consumers would save 48.6 million in
  direct medical costs.
• And, by year seven
• More than 6250 cumulative myocardial infarctions
  would have been averted.
• More than 1270 strokes would have been averted.
• Total averted medical costs of 280 million, of
  which 132 million (or 61) are from former
  passive smokers.

13
High Blood Pressure

• Nearly one in three adults has HBP.
• The prevalence of hypertension in blacks in the
  United States is among the highest in the world.
• Listed as a primary or contributing cause of
  death in about 277,000 deaths in 2003.
• The estimated direct and indirect cost for HBP in
  2006 is 63.5 billion.

14
High Blood Pressure

• Primary prevention goal
• Goal lt140/90 mm Hg lt130/85 mm Hg if renal
  insufficiency or heart failure is present
• Or lt130/80 mm Hg if diabetes is present.

15
High Blood Pressure

• Promote healthy lifestyle modification
• Advocate weight reduction
• Reduction of sodium intake
• Consumption of fruits, vegetables, and low-fat
  dairy products
• Moderation of alcohol intake
• Physical activity

16
High Blood Cholesterol

• A fat-like substance found in animal tissue and
  carried in the blood. Dietary cholesterol is
  present only in foods from animal sources such as
  whole milk dairy products, meat, fish, poultry,
  animal fats and egg yolks.

Build-up (plaque) in a blood vessel
17
High Blood Cholesterol

• Prevalence
• About 10 percent of adolescents ages 1219 have
  total cholesterol levels exceeding 200 mg/dL.
• Almost 100 million American adults have total
  blood cholesterol above 200 mg/dL.

18
High Blood Cholesterol

• Prevention
• Eat foods low in saturated fat, trans fat and
  cholesterol.
• Lose weight if you need to.
• Exercise for a total of at least 30 minutes on
  most or all days of the week.
• Some people may also need to take medicine,
  because changing their diet isn't enough.

19
High Blood Cholesterol

• Aftermath
• Less than half of persons who qualify for any
  kind of lipid-modifying treatment for CHD risk
  reduction are receiving it.
• Less than half of even the highest-risk persons,
  those who have symptomatic CHD, are receiving
  lipid-lowering treatment
• Only about a third of treated patients are
  achieving their LDL goal less than 20 percent of
  CHD patients are at their LDL goal.

20
Physical (In)Activity
21
(No Transcript)
22
Physical Inactivity

• Prevalence
• 31.3 percent of U.S. adults age 18 and older
  engage in any regular leisure-time physical
  activity (PA).
• The relative risk of CHD associated with physical
  inactivity ranges from 1.5 to 2.4, an increase in
  risk comparable to that observed for high blood
  cholesterol, high blood pressure or cigarette
  smoking.

23
Physical Inactivity

• Goal At least 30 minutes of moderate-intensity
  physical activity for adults.
• At least 60 minutes a day for children.

24
Physical Inactivity

• We cannot tell our citizens to walk and bike when
  there is no safe or welcoming place to pursue
  these activities that promote heart health.
• Promoting healthy and walkable community
  environments is essential both for personal
  health and for the long-term health of our
  communities.

25
Evidence Based Physical Inactivity Interventions

• Support a comprehensive physical activity program
  in school
• School-based physical education (the cornerstone)
• Require 150 minutes per week of physical
  education in grades K-6.
• Require 225 minutes per week of physical
  education in middle school.
• Require physical education for graduation.
• Do not allow waivers and substitutions for
  physical education.
• Develop quality physical education standards at
  the state level.
• Create PE Coordinators at the State Level
• Federal NCLB/ESEA Policy

26
Evidence Based Physical Activity Interventions

• Support a comprehensive physical activity program
  in school
• Support Physical Activity Before, After, and
  During School Support physical activity that is
  incorporated into the school day through
  elementary school recess, structured physical
  activity in classrooms, physical activity breaks,
  physical activity clubs, and special events.
• Promote walk/bike to school programs and the use
  of safe, well-maintained and close-to-home
  sidewalks, bike paths, trails, and recreation
  facilities.

27
Evidence Based Physical Inactivity Interventions

• Community-wide campaigns, including
  point-of-decision prompts

http//www.do-groove.com/
28
Evidence Based Physical Activity Interventions

• Creation of or enhanced access to places for
  physical activity combined with informational
  outreach activities
• Street-scale urban design and land use policies
  and practices
• Community-scale urban design and land use
  policies and practices

29
Overweight and Obesity

• Prevalence
• An estimated 9.2 million children and adolescents
  ages 619 are considered overweight or obese.
• Over 10 percent of preschool children ages 25
  are overweight, up from 7 percent in 1994.
• In 2003, an estimated 136,500,000 American adults
  were overweight, and 64,000,000 were obese.
• Since 1993, the prevalence of those who are obese
  increased over 61 percent.

30
Obesity Trends Among U.S. AdultsBRFSS, 1985
(BMI 30, or 30 lbs overweight for 5 4
person)
No Data lt10 1014
31
Obesity Trends Among U.S. AdultsBRFSS, 1990
(BMI 30, or 30 lbs overweight for 5 4
person)
No Data lt10 1014
32
Obesity Trends Among U.S. AdultsBRFSS, 1995
(BMI 30, or 30 lbs overweight for 5 4
person)
No Data lt10 1014
1519
33
Obesity Trends Among U.S. AdultsBRFSS, 2000
(BMI 30, or 30 lbs overweight for 5 4
person)
No Data lt10 1014
1519 20
34
Obesity Trends Among U.S. AdultsBRFSS, 2005
(BMI 30, or 30 lbs overweight for 5 4
person)
No Data lt10 1014
1519 2024 2529
30
35
Obesity

• Impact
• Obesity was associated with nearly 112,000 excess
  deaths
• Abdominal obesity is an independent risk factor
  for ischemic stroke in all racial and ethnic
  groups

36

• the first generation where children will die
  before their parents
• International Congress on Obesity. August 2002
• Actually, 8 million children and adolescents are
  overweight
• Over the last two decades the rates for
  overweight adolescents have tripled.
• Based on current trends 1 in 3 children born in
  the year 2000 will develop Type II Diabetes.
• A National Security Issue

37
Obesity

• Initiate weight-management program through
  caloric restriction and increased caloric
  expenditure as appropriate.
• Many obese and overweight people may have
  difficulty losing weight, but by losing even as
  few as 10 pounds, you can lower your heart
  disease risk.

38
The Search for Evidence Based Obesity
Interventions

• School-based interventions
• Worksite interventions
• Healthcare system interventions
• Community-wide interventions

39
Diabetes Mellitus

• Prevalence
• In 2003, the prevalence of physician-diagnosed
  diabetes was 14,100,000 the prevalence of
  undiagnosed diabetes was 6,000,000.
• Since 1990, the prevalence of those diagnosed
  with diabetes increased 61 percent.

40
Diabetes Mellitus

• Mortality
• At least 65 percent of people with diabetes
  mellitus die of some form of heart or blood
  vessel disease.
• Heart disease death rates among adults with
  diabetes are two-to-four times higher than the
  rates for adults without diabetes.

41
Diabetes Mellitus

• First step is diet and exercise.
• Second-step therapy is usually oral hypoglycemic
  drugs.
• Third-step therapy is insulin.

42
Nutrition

• The Economic Research Service of the USDA
  suggests that the average daily calorie
  consumption in the United States increased by 12
  percent between 1985 and 2000, or roughly 300
  calories.
• Between 1977 and 1996, portion sizes for key food
  groups grew markedly in the United States, not
  only at fast-food outlets but also in homes and
  at conventional restaurants.

43
Nutrition

• Impact
• Each year over 33 billion in medical costs and
  9 billion in lost productivity due to heart
  disease, cancer, stroke and diabetes are
  attributed to diet.

44
Nutrition

• Consumption of a variety of fruits, vegetables,
  grains, low-fat or nonfat dairy products, fish,
  legumes, poultry, and lean meats.
• Match energy intake with energy needs and make
  appropriate changes to achieve weight loss when
  indicated.
• Modify food choices to reduce saturated fats
  (lt10 of calories), cholesterol (lt300 mg/d), and
  trans-fatty acids by substituting grains and
  unsaturated fatty acids from fish, vegetables,
  legumes, and nuts.
• Limit salt intake
• Limit alcohol intake among those who drink.

45
Evidence Based Nutrition Interventions

• School-based nutrition programs
• Food and beverage advertising to children and
• Community approaches to increase fruit
  vegetable intake

46
Metabolic Syndrome

• Metabolic syndrome (MetS) is characterized by a
  group of metabolic risk factors in one person.
• The syndrome is associated with obesity and
  insulin resistance.
• Metabolic syndrome is considered a clustering of
  metabolic complications of obesity.

47
Metabolic Syndrome

• An estimated 1 million 1219-year-old adolescents
  in the United States have MetS, or 4.2 percent
  overall
• An estimated 47 million U.S. residents have MetS.
  The age-adjusted prevalence of MetS for adults is
  23.7 percent.
• People with MetS are about two times more likely
  to have prevalent CHD than those without the
  syndrome after adjusting for established risk
  factors.

48
Bottom Line

• Primary prevention of CVD risk factors can help
  prevent 80 percent of coronary heart disease and
  90 percent of type 2 diabetes

49
Secondary Prevention of Cardiovascular Disease

• There is a growing body of evidence confirms that
  aggressive comprehensive risk factor management
  improves survival, reduces recurrent events and
  the need for interventional procedures, and
  improves the quality of life
• The secondary prevention patient population
  includes those with established coronary and
  other atherosclerotic vascular disease, including
  peripheral arterial disease, atherosclerotic
  aortic disease and carotid artery disease.

50
Components of Secondary Prevention
51
Cigarette Smoking Recommendations
Goal Complete Cessation and No Exposure to
Environmental Tobacco Smoke

• Ask about tobacco use status at every visit.
• Advise every tobacco user to quit.
• Assess the tobacco users willingness to quit.
• Assist by counseling and developing a plan for
  quitting.
• Arrange follow-up, referral to special programs,
  or pharmacotherapy (including nicotine
  replacement and bupropion.
• Urge avoidance of exposure to environmental
  tobacco smoke at work and home.

52
Blood Pressure Control Recommendations
Goal lt140/90 mm Hg or lt130/80 if diabetes or
chronic kidney disease
Blood pressure 120/80 mm Hg or greater
Initiate or maintain lifestyle modification
weight control, increased physical activity,
alcohol moderation, sodium reduction, and
increased consumption of fresh fruits vegetables
and low fat dairy products

• Blood pressure 140/90 mm Hg or greater (or 130/80
  or greater for chronic kidney disease or
  diabetes)
• As tolerated, add blood pressure medication,
  treating initially with beta blockers and/or ACE
  inhibitors with addition of other drugs such as
  thiazides as needed to achieve goal blood
  pressure

53
Lipid Management Recommendations
For all patients
Start dietary therapy (lt7 of total calories as
saturated fat and lt200 mg/d cholesterol) Adding
plant stanol/sterols (2 gm/day) and viscous fiber
(gt10 mg/day) will further lower LDL Promote
daily physical activity and weight management.
Encourage increased consumption of omega-3
fatty acids in fish or 1 g/day omega-3 fatty
acids in capsule form for risk reduction.
54
Physical Activity Recommendations
Goal 30 minutes 7 days/week, minimum 5 days/week

• Assess risk with a physical activity history
  and/or an exercise test, to guide prescription
• Encourage 30 to 60 minutes of moderate intensity
  aerobic activity such as brisk walking, on most,
  preferably all, days of the week, supplemented by
  an increase in daily lifestyle activities
• Advise medically supervised programs for
  high-risk patients (e.g. recent acute coronary
  syndrome or revascularization, HF)

55
Weight Management Recommendations
Goal BMI 18.5 to 24.9 kg/m2 Waist Circumference
Men lt 40 inches Women lt 35 inches

• Assess BMI and/or waist circumference on each
  visit and consistently encourage weight
  maintenance/
• reduction through an appropriate balance of
  physical activity, caloric intake, and formal
  behavioral programs when indicated.
• If waist circumference (measured at the iliac
  crest) gt35 inches in women and gt40 inches in men
  initiate lifestyle changes and consider treatment
  strategies for metabolic syndrome as indicated.
• The initial goal of weight loss therapy should be
  to reduce body weight by approximately 10 percent
  from baseline. With success, further weight loss
  can be attempted if indicated.

BMI is calculated as the weight in kilograms
divided by the body surface area in meters2.
Overweight state is defined by BMI25-30 kg/m2.
Obesity is defined by a BMI gt30 kg/m2.
56
Diabetes Mellitus Recommendations
Goal Hb A1c lt 7
Lifestyle and pharmacotherapy to achieve near
normal HbA1C (lt7). Vigorous modification of
other risk factors (e.g., physical activity,
weight management, blood pressure control, and
cholesterol management as recommended).
Coordinate diabetic care with patients primary
care physician or endocrinologist. I (C)
HbA1c Glycosylated hemoglobin
57

• Antiplatelet Agents / Anticoagulation
  Recommendations

58

• Renin-Angiotensin-Aldosterone System (RAAS)
  Blockers Recommendations

59

• b-blocker Recommendations

60
Influenza Vaccination
Patients with cardiovascular disease should have
influenza vaccination
61
The Need to Implement Secondary Prevention

• Multiple studies of the use of these recommended
  therapies in appropriate patients continue to
  show that many patients in whom therapies are
  indicated are not receiving them in actual
  clinical practice.
• The AHA and ACC urge that in all medical care
  settings where these patients are managed that
  programs to provide practitioners with useful
  reminder clues based on the guidelines, and
  continuously assess the success achieved in
  providing these therapies to the patients who can
  benefit from them be implemented.
• Encourage that the AHAs Get With the Guidelines
  and/or ACCs Guidelines Applied to Practice
  Programs be instituted to identify appropriate
  patients for therapy

62
AHA GWTG Program
GWTG is a national initiative of the AHA to
improve guidelines adherence in patients
hospitalized with cardiovascular disease. GWTG
uses collaborative learning sessions, conference
calls, e-mail and staff support to assist
hospital teams improve acute and secondary
prevention care systems. A web-based Patient
Management Tool is used for point of care data
collection and decision support, on-demand
reporting, communication and patient education.
63
Secondary Prevention Conclusions

• Evidence confirms that aggressive comprehensive
  risk factor management improves survival, reduces
  recurrent events and the need for interventional
  procedures, and improves the quality of life for
  these patients.
• Every effort should be made to ensure that
  patients are treated with evidence-based,
  guideline recommended, life-prolonging therapies
  in the absence of contraindications or
  intolerance.

64
Quality and Availability of Care Policy

• Promote Adherence to Clinical Guidelines
  Treatment Protocols
• Promote Quality and Performance Indicators
• Promote Access to Health Coverage
• Monitor Pay-for-quality and Non-financial
  Incentives
• Monitor Drug Formulary Policy
• Monitor Health Information Technology

65
What should we be working towards in HIT?
66
What should we be working towards in HIT? (Cont.)
67
Additional Information

• Jill Birnbaum
• State Advocacy Consultant
• jill.birnbaum_at_heart.org
• 952-278-3643

68

Q
A
Questions?