Cardiovascular Risk Factor Overview and Management

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• ??????????????? (Atherosclerosis)
• ??????????????????????????
• Complex inflammatory-fibroproliferative response
  to retention of plasma-derived atherogenic
  lipoproteins in the arterial intima.

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Epidemiologic Transition, MexicoDecline in
Communicable, Rise of NCDs
5
????????????????????????????????????? ?.?2510-2540
Death rate per 100,000
90
80
CVD
2007 ?

70
Accident
Cancer
60
AIDS
50
Pneumonia
Diarrhea
40
30
20
10
1967 1977
1997
Year
Bureau of Health Policy and Plan and Division of
Epidemiology, MOPH
6
Lifestyle Factors
Genes load the gun.Lifestyle pulls the trigger
Dr. Elliot Joslin
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Risk Factors
Atherosclerosis
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Risk factors
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(No Transcript)
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Modifiable
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Beyond Cholesterol Predicting CV Risk In the
21st Century
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The Metabolic Syndrome andAssociated CVD Risk
Factors
Insulin Resistance
Deedwania PC. Am J Med 1998105(1A)1S-3S.
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Estimated Proportion of CHD Events Preventable
by Control of Blood Pressure, HDL-C, LDL-C, and
All 3 Factors to Optimal Levels in Persons with
the Metabolic Syndrome (Wong et al., Am J
Cardiol, June 15, 2003)


plt0.05, plt0.01 compared to men
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Steno 2 Effects of Intensive Therapy on Combined
CV Outcomes
Primary composite endpoints
From P Gaede, et al. NEJM 348383-393, 2003
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Optimizing Diabetes CareNumber Needed to Treat
(NNT)

• NNT 1/absolute risk reduction (AAR)
• AAR Event rate (control) event rate
  (treatment)
• Microvascular complications
• UKPDS (? blood glucose) 39.2
• UKPDS (? blood pressure) 12.2
• Steno (? BG, BP, lipid and UAE) 1.5
• Major CHD
• HOT study 16
• 4S study 5
• CARE study 12
• Screening for breast cancer 1000

From P Gaede et al, NEJM 348383-393, 2003
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Modifiable
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  ?? ??????????????????????????????????????????
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• Primary prevention ?????????????????????????????
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• Secondary prevention ???????????????????????????
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Characteristics of the Levels of Prevention

• Well-defined target population
• Well-defined objectives and goals
• Consistent with AHA/ACC definitions and
  guidelines for primary secondary prevention

• Consistent with Healthy People 2010 goals and
  objectives for heart disease and stroke focus area

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(No Transcript)
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Levels of Prevention
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Prevention and Control of Heart Disease and
StrokeA Summary Scheme and Characteristics of
Prevention Levels
Level of Prevention
Target Population
Goals of Prevention
Published Guides
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Levels of Prevention and theCore Functions of
Public Health
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Public Health Roles in Comprehensive CVD
Prevention
www.health.gov/phfunctions/public.htm
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(No Transcript)
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Percentage change in CVD death rates in people
aged 35-74 y 1988-1998
Denmark
Australia
Luxembourg
Sweden
Netherlands
USA
Portugal
Greece
Hungary
Japan
Romania
Ukraine
Belarus
Kazakhstan
Croatia
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??????????????????????

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  ?????????????-??
• Policy, Environment
• Legislation, taxation
• City planning
• Education
• Social marketing and advocacy, mass media
• Specific settings
• Technology
• Agriculture
• Food industry

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Relative Roles of Education and Regulation Within
Different Levels of Government
Top down
REGULATIONS AND LAWS
INTERNATIONAL COUNTRY PROVINCE /
REGION COUNTRY COMMUNITY
EDUCATION
Bottom up
Catalonia Declaration Investing in Heart
Health. Department of Health and Social Security,
Autonomous Government of Catalonia ,1996
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Cholesterol and CHD Seven Countries Study
Northern Europe United States Southern Europe,
Inland Southern Europe, Mediterranean Siberia Japa
n
30
25
20
CHDmortality rates()
15
10
5
0
100
125
150
175
200
225
250
275
300
325
350
(2.60)
(3.25)
(3.90)
(4.50)
(5.15)
(5.80)
(6.45)
(7.10)
(7.75)
(8.40)
(9.05)
TC mg/dL (mmol/L)
Verschuren WMM et al. JAMA. 1995274131-136.
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• ?????????????????????????? 1 ????? ??????? lipid
  profile (Total cholesterol, TG, HDL-C)
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• ???? lipid profile (Total cholesterol, TG, HDL-C)
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• ??????????????????????? (Rama-EGAT score)
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???????????? ??? coefficients ?????
???? 35 39 (37) 40 44 (42) 45 49 (47) 50 54 (52) -.385 0 .385 .770 -1 0 1 2
BP SBPlt120,DBPlt80 SBP 120 - 129 DBP 80 84 SBP 130 - 139 DBP 85 89 SBP 140 - 159 DBP 90 99 SBP gt 160 DBP gt 100 .119 0 .333 .516 .958 0 0 1 1 2
Total cholesterol lt 160 160 199 200 279 gt 280 - .675 0 - .100 .631 -2 0 0 2
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???????????? ??? coefficients ?????
HDL lt 35 35 49 50 59 gt 60 .655 0 - .298 - 2.033 2 0 -1 -5
Current smoker No Yes 0 . 519 0 1
DM No Yes 0 .904 0 2
Waist gt 90 cm No Yes 0 .568 0 1
Alcohol drinker No Yes 0 - .788 0 -2
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lt -3 lt1
-2 1
-1 1
0 1
1 2
2 3
3 5
4 7
5 10
6 14
gt 7 gt 20
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Result of Risk Reduction Strategies in
Patients with Establish Cardiovascular Disease
Intervention
Cardiovascular Event Reduction ()
Total Mortality Reduction ()
Smoking cessation Lipid lowering Exercise Aspirin
therapy Anticoagulant therapy ACE inhibitor
therapy Beta- blocker therapy Blood pressure
control
- 42 25 30 53 25 26 21
43 30 20 15 10 20 27 12
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47
????????????????????????????????????? ?.?2510-2540
Death rate per 100,000
90
80
CVD
2007 ?

70
Accident
Cancer
60
AIDS
50
Pneumonia
Diarrhea
40
30
20
10
1967 1977
1997
Year
Bureau of Health Policy and Plan and Division of
Epidemiology, MOPH
48
?????????????????? 10 ??????????????????

• ???
• ???????????? ?????
• 1. ????? 37545 16
• 2. ????????????? 21043 9
• 3. ?????????? 19851 8
• 4. ????????? 16613 7
• 5. ???????????? 12262 5
• 6. ?????????????? 11238 5
• 7. ????????? 7622 3
• 8. ??????? 7282 3
• 9. ??????? 6552 3
• 10.?????? 6473 3

• ????
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• 1. ????????????? 25053 15
• 2. ????? 13707 8
• 3. ??????? 12784 8
• 4. ?????????????? 8597 5
• 5. ????????? 8162 5
• 6. ?????? 5530 3
• 7. ???????????? 5494 3
• 8. ?????? 4615 3
• 9. ?????????? 4585 3
• 10.????? 4272 3

??????????? ???????????????????????????
???????????????? ?? 2542
49
????????????????????????????????????

• ???
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• 1. ????? 960 ,086 17
• 2. ?????????? 510 ,909 9
• 3.????????????? 271 ,009 5
• 4. ????????? 248 ,083 4
• 5. ??????? 168 ,594 3
• 6. ????????????? 159 ,188 3
• 7. ???????????? 156 ,861 3
• 8. ???????? 156 ,853 3
• 9. ????????? 147 ,988 3
• 10. ???????? 137 ,703 2

• ????
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• 1. ????? 372 ,956 10
• 2. ????????????? 282 ,509 7
• 3. ??????? 267 ,155 7
• 4. ???????? 145 ,336 4
• 5. ????????? 118 ,384 3
• 6. ????????? 117 ,994 3
• 7. ??? 112 ,990 3
• 8. ?????????? 108 ,449 3
• 9. ?????????????? 102 ,863 3
• 10. ???????? 96,091 2

??????????? ???????????????????????????
???????????????? ?? 2542
50
Crude death rates, Thailand, 1999
????????????? ????????????????????????
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51
?? 2542

• ???????????????????????????? ????? 126 ??
  ????????? 5.3 ??
• ????????????????????? ????? 54 ?? ????????? 2.3
  ??
• ?????????????? ????? 55 ?? ????????? 2.3 ??
• ?????? ???????????? ?????????????????????,
  ??????????????, ?????????? ????? 236 ??
  ????????????? 10 ?? ???? ???? 6
  ????????????????????????? 1 ??

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52
???????????????????????????????????????????????
4 Cohort study
???????? EGAT ??????? ?.?????? ???????????
??????????????? 1985-1997 1989-1999 1996-2001 1988-1998
???????????????? 3318 985 1793 1876
????????? (???) 165 80 17 83
????????????????????
???????????????????? 46 (28) 18 (23) 10 (59) 18 (22)
????????????????? 24 4 6 NA
????????????????? 4 5 - NA
???????????????? 2 2 - NA
???????????????? 16 7 4 NA
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Crude death rates (per 1,000),among EGAT
employees aged 35-64,yr1985-1997
Modified from Int Epid J 200332461-468
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??????????????????????????????????????????????
Relative Risk (95 CI) Relative Risk (95 CI)
??????????????? ?????????????????????????????
??????????????? ??? 3.22 (1.49-6.96) 4.13 (1.91-8.91)
???? 4.05 (1.68-9.78) 5.18 (1.95-13.73)
??????????????? ??? 1.60 (0.64-3.96) 1.29 (0.76-2.17)
???? 2.57 (1.10-6.02) 3.19 (0.83-12.27)
HDL-C ??? ??? 0.74 (0.56-0.99) 0.49 (0.24-1.02)
???? 0.43 (0.16-1.13) 0.35 (0.08-1.44)
??????? ??? 1.98 (1.00-3.93) 2.36 (0.89-6.28)
???? 3.89 (1.52-9.99) 7.94 (2.23-28.30)
????????? ??? 1.55 (1.02-2.37) 1.43 (0.49-4.17)
???? 2.28 (0.75-6.96) 6.53 (2.22-19.17)
??????? ?????? 2546
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?????????????????????????????????????????
?????????? ???????? ?????????????? 1 2534-35 ???????? ?????????????? 2 2539-40 ???????? InterASIA 2543-44
Systolic blood pressure 119 125 120
Diastolic blood pressure 77 75 76
??????????????????? () 27 28 22
????? Cholesterol ??????_ (mg/dl) 189 198 201
????????? Cholesterol ???_() 14 19 18
?????????????????? ??????_(mg/dl) 87 92 99
???????????_() 3.1 8.1 7.7
Body mass index_BMI (kg/m2) 22.8 23.8 24.4
???????????_() 20 25 30
???????_() 5 8 9
????????????_() 37 29 27
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Prevalence of Hypercholesterolemia
(Chol ?240 mg/dL or on medication)




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Prevalence of current smoking




InterASIA 2000
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Levels of Risk Associated with Smoking,
Hypertension and Hypercholesterolaemia
Hypertension (SBP 195 mmHg)
x3
x9
x4.5
x16
x1.6
x4
x6
Smoking
Serum cholesterol level (8.5 mmol/L, 330 mg/dL)
Adapted from Poulter N et al., 1993
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Estimated Proportion of CHD Events Preventable
by Control of Blood Pressure, HDL-C, LDL-C, and
All 3 Factors to Optimal Levels in Persons with
the Metabolic Syndrome (Wong et al., Am J
Cardiol, June 15, 2003)


plt0.05, plt0.01 compared to men
61
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