Title: Prevention%20of%20Cardiovascular%20Diseases:%20Begin%20in%20Childhood!
1Prevention of Cardiovascular Diseases Begin in
Childhood!
- Ruth Collins-Nakai
- MD, MBA, FRCPC, FACC
- President
- InterAmerican Society of Cardiology
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3 Outline
- World status of CVDs
- Argentinean status of CVDs
- Prevention efficacy
- Recommendations re risk factors
- Role of CV specialist in prevention
4World Status of CVD
- Represents 30 of all deaths worldwide (15
million deaths/year) - Leading cause of death and disability
- CVD burden ? in developing countries
- Risk factors ? worldwide
5 GDP spent on health
6Population per Physician
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8Argentina CVD mortality females
9Argentina CVD mortality
females
10Argentina IHD mortality males
11Argentina Diabetes females
males
12Atherosclerosis A Systemic Disease
13Prevention Facts
- Defined Risk Factors in adults associated with
accelerated atherosclerosis and CVD rates - Atherosclerosis begins in childhood
- Extent of atherosclerosis in children correlated
with same risk factors as in adults - Strong JP et al JAMA 1999281727-735
- Berenson GS et al NEJM 19983381650-1656
- Williams CL et al Circ. 2002106143-160
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15Early Appearance of Atherosclerosis Bogalusa
Heart Study
Prevalence of Fibrous Plaque Lesions
80
Aorta
Coronary Arteries
60
40
20
0
2-15
16-20
21-25
26-39
2-15
16-20
21-25
26-39
Age (Years)
p 0.001 for trend toward increasing prevalence
with age in aorta and coronary arteries.
16The Evidence
- ?physical activity associated with ? life
expectancy - Direct association between obesity insulin
resistance in children - Direct association between obesity lipid levels
in children - Tracking BMIgtweightgtskinfold thicknessesgtlipidsgtB
P - Clusters of multiple risk factors persist
strongly from child-to-adulthood
17Risk Factors for Atherosclerosis
- Smoking
- Obesity
- High blood pressure
- Physical Inactivity
- High blood fat levels
- Diabetes
- Positive family history
- Other (ethnicity, anger)
18Effect of Multiple Risk Factors on Probability of
CAD Framingham Study
40
21
10-Year Probability of Event
14
10
6
4
SBP 150-160 Cholesterol 6.2-6.8
- HDL-C 0.8-0.9 - - Diabetes
- - - Cigarettes - - - - ECG-LVH - -
- - -
19Recommendations
- Cardiovascular Health in Childhood (AHA
Scientific Statement) - Circ 2002106143-160
- Circ 20021071562-1566
- Canadian Cardiovascular Society Consensus
Conference on Prevention of CVD The Role of the
CV Specialist - CJC 199915(supple.G)
20Smoking
21Tobacco
- Complete cessation for those who smoke
- No exposure to environmental tobacco smoke
- No new initiation of cigarette smoking or tobacco
use
22Obesity
- Appropriate body weight (BMI for age)
- (www.cdc.gov/growthcharts./)
- Overall healthy eating pattern (limit salt, fat,
calories sugar gt 2 years age) - Balance Energy in energy out for weight
- Begin treatment before adolescence
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24Trends in prevalence of overweight in
USA (CDC NHANES)
20
15
10
5
0
1963-70
1971-74
1976-80
1988-94
1999
6-11 yrs
12-19 yrs
25Physical Activity
- Physical activity every day (60 minutes per day
for children) - Reduce/limit sedentary time (e.g.. TV maximum 2
hours per day) - May add resistance training to aerobic activity
in adolescents
26Lipids Lipoproteins
- Total cholesterol lt4.4 mmol/L recommended
(USAgt170mg/dL borderline gt200 mg/dL is ?) - LDL-C lt2.85 mmol/L recommended (USAlt110mg/dL)
- Triglycerides lt1.5 mmol/L recommended (USA lt150
mg/dL) - HDL-C gt35 mg/dL recommended
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29Effect of SBP and DBP onAge-Adjusted CAD
Mortality MRFIT
CAD Death Rate per 10,000 Person-years
80.6
48.3
43.8
38.1
37.4
34.7
31.0
25.3
25.2
25.8
24.9
24.6
23.8
160
13.9
16.9
12.6
11.8
12.8
20.6
140-159
10.3
11.8
8.8
8.5
9.2
120-139
lt120
100
90-99
80-89
75-79
70-74
lt70
Systolic BP (mmHg)
Diastolic BP (mmHg)
30Blood Pressure
- Systolic diastolic BPgt90th for age, sex and
height is abnormal (www.nhlbi.nih.gov/health/prof/
heart/hbp/hbp_ped.htm.) - gt130/80 is almost always pathological in youth.
- Use proven effective therapies recommended for
adults (CPGs)
31Diabetes
- Adequate nutrition (neither over nor
undernutrition) of pregnant women Barker
hypothesis - Limit sugar intake
- Maintain normal weight for age height
- For type 1 diabetics, ongoing strict control (Hgb
A1c)
32Other Risk Factors
- Ethnicity (esp. South Asian / aboriginal/black/His
panic) - Low socioeconomic level
- Social isolation
- Depression
- Pregnancy (HTN and gestnl diabetes)
- Emerging risk factors
33Childhood Abuse
- Adverse childhood experiences (ACEs)
- 1.7x ? risk with emotional abuse
- 1.7x ? risk with crime in household
- 1.3x ? risk with emotional neglect
- 1.3x ? risk with substance abuse
- Depressed affect OR 2.1
- Anger OR 2.5
- 7 or gt ACEs ? risk almost 4x
- Dong M et al CIRC 110 2004
34Clinical Application of the Concept of Risk
-
Vascular, unstable
Pluri-vascular
Diabetic risk factors
Vascular
Diabetic
Asymptomatic risk factors
Asymptomatic
Symptomatic
35Economic Burden of Coronary Artery Disease (CAD)
Direct and Indirect Cost of CAD Country (not
adjusted for inflation)
US (2000) 118.2 billion USD Canada (1993) 19.6
billion CDN (15.2 of total economic burden of
illness) UK (1996) 10 billion Germany (1996) 112
billion DM Taiwan (1991) 9.0-11.9 billion new
Taiwan Sweden (1994) 276 billion SEK
36BMI
lt75ile
75-85ile
85-95ile at risk for ow
gt95ile overweight
Reaffirm healthy Habits f/u annually
Assess family history, food habits, activity
Council to change food intake increase
physical activity
Council to change food intake increase
physical activity
Assess RF If gt1 RF, treat as gt95ile
Assess RF Treat RFs Involve family
Nesbitt SD et al Ethnicity Disease 142004
37 Role of Cardiovascular Specialist
- Education of other health care personnel
- Advocate for heart healthy public policies
- Treat individual patients, including children
with significant risk factors.
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39Conclusions
- The burden of global CVD is increasing
- The burden of risk factors is rising alarmingly
in children and youth - Cardiovascular specialists have an obligation to
lead in prevention - Educate, Advocate, Treat
40Gracias!
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