Cardiovascular Disease Preventive Medicine 2005

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Cardiovascular DiseasePreventive Medicine 2005

• David R. Rudy, M.D., M.P.H.
• Professor and Chairman
• Family and Preventive Medicine
• Chicago Medical School, RUMS

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Atherosclerotic Vascular Disease

• Risk Factors,
• Screening to Prevent

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Atherosclerotic Disease

• Coronary artery disease (CAD)
• Cerebrovascular disease CVD)
• Peripheral vascular disease (PVD)
• Reno-vascular dis. and renal failure (CRF) gtgt
  hypertension

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Coronary Artery Disease (CAD)

• 1.5 million myocardial infarctions (MI)/year/US
  700,142 deaths from CAD
• 15 case fatality w/ acute MI 30 case fatality
  w/ acute MIs as first indication of CAD
• Riskshigh BP, dyslipidemia, physical inactivity,
  diabetes mellitus, age. (obesity)
• Smoking
• Genetics

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Screening versus Prevention (1)

• Screening for CAD in general population is
  impractical (e.g. screening EKGs, stress testing,
  coronary angiograms)
• Resting EKGs not sensitive enough EKG stress
  testing not sensitive enough in high risk
  populations
• Thallium stress/EKG too sensitive in low risk
  populations
• Coronary angiograms too risky and too expensive
  for screening

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Screening versus Prevention (2)

• Primary (and secondary) prevention of CAD through
  control of controllable risk factors
• Screening is for risk factors imperfect but cost
  effective and tolerable

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Risk factors for CAD (and other athero-sclerotic
vascular dis

• Controllable Hypertension, diabetes,
  dyslipidemia, smoking, C-reactive protein,
  (emotional stress)
• Uncontrollable inheritance

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Risk factors tend toward clusters hypertension,
diabetes, dyslipidemia

• Metabolic syndrome X and insulin resistance
  (strong assoc. w/ obesity strongly familial but
  remediable)

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Metabolic Syndrome X

• Insulin resistance, hyperinsulinemia, incipient
  diabetes type II
• Hypertension
• Dyslipidemia ? TC, LDLC, TGs, ? HDLC

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Criteria for metabolic syndrome X any 3/5

• 1. Abdominal obesity waist measurement gt 102 cm
  (40 in.) in men, 88 (35 in.)cm in women.
• 2. Hypertrigyceridemia ? 150 mg/dL (?1.69
  mmol/L)
• 3. Low HDL cholesterol ? 40 mg/dL (1.04 mmol/L)
  lt 50 mg/dL for women
• 4. High blood pressure ?130/85 mm Hg or
  hypertension under treatment
• 5. High fasting blood glucose ? 110 mg/dL (6.1
  mmol/L) or taking Rx for D/M
  Executive Summary of the Third Report of the NCEP
  etc. (ATP III). JAMA 2001 2852486-2496

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Relationship between diabetes and hypertension

• Diabetics have a 50 prevalence of hypertension
  (compare to 15-20 of US population) even when
  corrected for weight
• Hypertensives have prevalence of glucose
  intolerance (abn BS patterns) 15-18 (compare
  to 5-6 of adult US pop. w D/M) - a significantly
  larger percentage is assumed to have insulin
  resistance w/o glucose intolerance

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Obesity, diabetes, hypertension and dyslipidemia

• 80-90 of type II diabetics are obese
• Prevalence of obesity and of diabetes type II
  have risen in parallel since 1980.
• 33 increase in prevalence of D/M between 1990
  and 1998

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CAD electrocardiogramresting EKG as screen

• ST depression, T wave inversion, Q waves, LVH may
  diagnose CAD.
• However, seldom CAD presents w/o symptoms so EKG
  poor screen.
• E.g.in CAD occurs in 1-4 of middle aged men w/o
  sympts
• of those, 3-15 developed symptomatic CAD over
  5-15 years.

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CAD electrocardiogramresting EKG as screen (2)

• 1-4 of middle aged men have CAD w/o symptoms
  (angiographic proof)
• of those, 3-15 developed symptomatic CAD over
  5-15 years
• Thus, at most, prevalence of CAD in asymptomatic
  males 0.6 of middle aged men

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CAD screening and EKG (3)

• EKG is neither very sensitive (only 29 of
  angiogram proven disease had ST,T or voltage
  changes)
• Nor specific - Nonspecific T ? common
• Resting EKG most useful for baseline and future
  comparison

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CAD screening and EKG (4)

• Stress testing (EKG only) more sensitive and
  specific than resting EKG, but many false (not
  specific enough
• Still, only 1-11 w/ abnormalities suffered acute
  MI or sudden death when followed over 4-13 years
• Addition of thallium scintigraphy scan proves
  more sensitive but less specific in low risk
  population.

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CAD screening and EKG (5)

• Only 1-11 w/ abnormalities suffered acute MI or
  sudden death when followed over 13 years
• 0.045 (4/10,000) of resting EKGs will diagnose
  asymptomatic CAD

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CAD screening and (EKG) - (7)

• Stress testing OK in higher risk states - e.g.
  out of shape middle aged ex-athletes before
  embarking on exercise program- usually EKG w/o,
  e.g. thallium
• Atypical chest pain w/ dyslipidemia, Obesity
  and/or hypertension, w/ thallium
• EKG is most useful in the acute situation

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Best application for Scanned Stress Testing

• Diagnosis of chest pain (I.e. not a screening
  situation)

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Criteria for CAD Screening I

• The conditions must have a significant effect on
  the quality or quantity of life (YES).
• Acceptable methods of treatment must be available
  for the condition (YES).
• The condition must have an asymptomatic period
  during which detection and treatment
  significantly reduce morbidity or mortality
  (YES).
• Treatment in the asymptomatic phase must yield a
  therapeutic result superior to that obtained by
  delaying treatment until symptoms appear (not
  settled).

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Criteria for Screening II

• Tests that are acceptable to patients must be
  available at reasonable cost to detect the
  condition in the asymptomatic period. Corollary
  Sensitivity and specificity must be appropriate
  for the risk status of the population being
  screened (NO and NO).
• The incidence of the condition must be sufficient
  to justify the cost of screening (YES).

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Significance of hypertension

• Prevalence US said to be 58 million (20 of the
  entire population, adults and children)
• Leading risk factor for stroke
• When neglected, presents as hypertensive heart
  disease (LVH, pulmonary edema), CAD
• Largely asymptomatic

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Hypertension

• Ranking risk factor for strokegt CADgt Renal
  Failuregt

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Pathophysiology of essential hypertension

• 35 Caucasians and most other groups
  hypertension characterized by salt/water
  retention 65 African-Americans majority of
  elderly
• 10 peripheral vascular resistance (PVR)
  (renin/angiotensin, catecholamines)
• 55 mixed PVR/salt retention)
• Hyperinsulinemia associated w/ volume dependent
  hypertension

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Hyperinsulinemia associated w/ mineralo-corticoid,
probable contributor to volume dependent
hypertension

• Salt/water retention driven hypertension responds
  to diuretics thiazides gt loop diuretics (except
  in rising creatinine)-
• - and to salt restriction
• What portion of most groups hypertension have
  pure salt sensitivity? 35
• Which portion of African-Americans hypertension?
  67

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Salt Restriction opportunity for primary
prevention of hypertension(Other mainstays of Rx
of hypertension ACEIs and ACERBs, Ca channel
blockers, ß blockers)
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Definitions of Hypertension (HTN)

• Three readings on separate
• occasions (gt140/gt90) to make
• the diagnosis, unless BP is
• found at gt210/gt120

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Htn in Children 95th-99th percentiles

• Age group
• Newborns _at_ 30 d
• Infants
• 3-5 years
• 6-9 years
• 10-12 years
• 13-15 years
• 16-18 years

• SBP/DBP, mm Hg
• 104-109 SBP
• 112-117/74-81
• 116-123/76-83
• 122-129/78-85
• 126-133/82-89
• 136-143/86-91
• 142-149/82-97

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Physiologic Types of Hypertension

• I Essential or Primary Hypertension (90-95 of
  all cases)
• II Secondary Hypertension
• 5-10 of all cases (pheo, primary
  aldosteronism, renovascular)
• (Zollo The Portable Internist. Hanley and
  Belfus/Philadelphia and Moseby/St. Louis 1995)

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Primary and secondary prevention HTN w/o drugs

• Weight control to prevent HTN (and to prevent
  insulin resistance)
• Control sodium intake to prevent 1/3 HTN useful
  adjunct in addtional 1/3
• Stress management
• Control of other aggravating risk factors
  e.g. smoking, dyslipidemia

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Isolated Systolic Hypertension (ISH SBP140)

• CVD risk
• More common in elderly elderly more likely to
  have ISH likely to be diuretic responsive.

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Factors in primary prevention of Htn in high risk
people

• -salt restriction
• -stress management
• -weight control

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Implications of hypertension and of diabetes re/
kidneys

• Status of renal function

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Major causes of chronic renal failure (not ESRD)
sub w/ Bakris

• Diabetes mellitus 31.0
• Hypertension 27.0
• Glomerulonephritis 14.0
• Obstructive uropathy 5.7
• Polycystic renal disease 3.6
• Others 5.7
• Unknown 13.0

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DiabetesThe Most Common Cause of ESRD
Primary Diagnosis for Patients Who Start Dialysis
Glomerulonephritis
Other
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10
No. of patients
700
Projection
95 CI
600
500
400
No. of dialysis patients (thousands)
520,240
300
281,355
200
243,524
100
r299.8
0
1984
1988
1992
1996
2000
2004
2008
United States Renal Data System. Annual data
report. 2000.
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Prevention of End Stage Renal Disease by BP and
BS control

• Tight control of blood sugar and of BP prevents
  ESRD in diabetics and hypertensives.
• Diabetes Control and Complications Trial Research
  Grp. Diabetes Care 1995 United Kingdom
  Prospective Diabetes Study 1998

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Recommendations for screening for HTN (USPSTF,
1996)

• Screening for hypertension is recommended for
  all children and adults, i.e. BPs on all visits

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Secondary Prevention of Complications of D/M
through control of BS, insulin resistance UKPDS

• Metformin as good as S.U.s in BS control but MI
  mortality reduced by 39 w/ metformin (b/c
  reduces insulin)
• Hgb A1C controlled to lt 7.0 instead of 7.9
  reduced retinopathy by 29, nephropathy by 33,
  and neuropathy by 40
• (many now cut Hgb A1C lt 6.4

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Dyslipidemia

• Prevention and screening

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ATP III criteria for lipid levels, ideal

• LDL cholesterol lt 100mg/dL
• Total cholesterol lt200mg/dL
• HDL cholesterol 40 mg/dL (men) JAMA. 2001
  2852487-2497

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Lipid levels when to apply diet

• Total cholesterol start diet _at_ gt200
• LDLC diet for 160 mg/dL
• HDLC diet at lt 40
• TCHDLC ratio gt 5.1 males, gt 4.1 females,
• TG diet for gt 150

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Dietary goals

• Fats 30 total cal as saturated lt7
  polyunsaturated 10
  monounsaturated 20
• Carbos 50-60 of cal complex
• gt simple
• Fiber 20-30 gm
• Protein 15 of total calories
• Cholesterol lt 200 mg/day

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More liberal use of the HMG Co-enzyme A
inhibitors (statins)

• Increasingly believed that people w/ mild to
  moderate risk factors benefit from statins
• the foregoing includes even women and elderly
  (gt75 y.o.)
• That LDL should not exceed 100 mg/dL
• That everyone should have a lipid profile every 5
  years.

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More liberal definition of risk status

• From Framingham study, people w/ two risk
  factors should be treated as if they have already
  a diagnosis of CAD.
• People w/ diabetes alone to be treated as if they
  have already a diagnosis of CAD.

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Significance of CRPRidker J.A.M.A. 2001
2852481-2485Ridker New Engl J Med 2004
35220-8

• Marker of over exuberant inflammatory response,
  relevant in endothelial injury and repair
• Highest quartile of CRP exhibits RR of 1.5 times
  expected risk for atherosclerotic disease

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CRP continued

• AS is a disease of endothelial defectiveness -
  failure causes rupture of plaques
• CRP levels, along with Total and Low Density
  Lipoprotein Cholesterol are reduced by statins

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Recommendation for lipid screening
(USPSTF)USPSTF Guide to Clinical Preventive
Services Second Edition. Williams and Wilkins 1996

• -periodic measurement of cholesterol for all men
  35-65 and women 45-65- and it may also be
  clinically prudent for healthy men and women
  65-75

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Primary prevention of dyslipidemia

• Weight control
• Qualitative diet adjustments
• Exercise

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Prevention of Stroke (1)

• First, control of risk factors
• Htn, smoking, lipids, diabetes

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Screening for stroke susceptibility (2)

• Carotid stenosis of 75 carries 2 risk of
  stroke/year.
• ACAS study showed stroke reduction over a five
  year period to 5.8 - 4.8 from 10.5, by
  preemptive carotid endarterectomy (a reduction of
  relative risk of 55 J.A.M.A. 1995 273
  1421-28

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Screening for stroke w/ carotid bruit (3)

• Doppler ultrasound yields 87 sensitivity and 91
  specificity, for stenosis.
• Carotid angiogram is gold standard.