1. International Comparisons in CVD Morbidity and Mortality
CVD accounts for 25-45% of deaths among different countries
CVD death rates (per 100,000) range from 1310 in Russia to 201 in Japan (6.5 fold difference) in men and from 581 in Russia to 84 in France (7-fold difference)
USA ranks 16th for both men (413) and women (201)

2. Secular Trends in CHD and Stroke Mortality
From , greatest annual decline (6-7%) in CHD seen in Israel among men and France among women, USA intermediate (4%), increases in Poland and Romania.
Stroke death rates declined most in Australia, Italy, and France (8-9%), USA about 3%.

3. Age-Adjusted Death Rates for Coronary Heart Disease by Country and Sex, Ages 35-74, 1999
Age-Adjusted to European Standard
Data for 1999 unless noted
Source: NHLBI 2002 Chart Book on Cardiovascular, Lung, and Blood Diseases

4. Age-Adjusted Death Rates for Stroke by Country and Sex, Ages 35-74, 1999
Age-Adjusted to European Standard
Data for 1999 unless noted
Source: NHLBI 2002 Chart Book on Cardiovascular, Lung, and Blood Diseases

5. Change in Age-Adjusted Death Rates for Coronary Heart Disease by Country and Sex, Ages 35-74,
Men
Age-Adjusted to European Standard
Latest data year note in parentheses
Source: NHLBI 2002 Chart Book on Cardiovascular, Lung, and Blood Diseases
Women

6. Change in Age-Adjusted Death Rates for Stroke by Country and Sex, Ages 35-74, 1990-1999
Men
Age-Adjusted to European Standard
Latest data year note in parentheses
Source: NHLBI 2002 Chart Book on Cardiovascular, Lung, and Blood Diseases
Women

7. Migrant Studies
Ni-Hon-San Study showed Japanese living in Japan to have the lowest cholesterol levels and lowest rates of CHD, those living in Hawaii to have intermediate rates for both, and those living in San Francisco to have the highest cholesterol levels and CHD incidence

8. Approaches to Primary and Secondary Prevention of CVD
Primary prevention involves prevention of onset of disease in persons without symptoms.
Primordial prevention involves the prevention of risk factors causative o the disease, thereby reducing the likelihood of development of the disease.
Secondary prevention refers to the prevention of death or recurrence of disease in those who are already symptomatic

9. Risk Factor Concepts in Primary Prevention
Nonmodifiable risk factors include age, sexc, race, and family history of CVD, which can identify high-risk populations
Behavioral risk factors include sedentary lifestyle, unhealthful diet, heavy alcohol or cigarette consumption.
Physiological risk factors include hypertension, obesity, lipid problems, and diabetes, which may be a consequence of behavioral risk factors.

10. Population vs. High-Risk Approach
Risk factors, such as cholesterol or blood pressure, have a wide bell-shaped distribution, often with a “tail” of high values.
The “high-risk approach” involves identification and intensive treatment of those at the high end of the “tail”, often at greatest risk of CVD, reducing levels to “normal”.
But most cases of CVD do not occur among the highest levels of a given risk factor, and in fact, occur among those in the “average” risk group.
Significant reduction in the population burden of CVD can occur only from a “population approach” shifting the entire population distribution to lower levels.

11. Pyramid of Risk (Werner et al
Pyramid of Risk (Werner et al. Canadian Journal of Cardiology 1998; 14(Suppl) B:3B-10B)

12. Expected Shifts in Cholesterol Distribution from High-Risk, Population, and Combined Approaches

13. Population and Community-Wide CVD Risk Reduction Approaches
Populations with high rates of CVD are those with Western lifestyles of high-fat diets, physical inactivity, and tobacco use.
Targets of a population-wide approach must be these behaviors causative of the physiologic risk factors or directly causative of CVD.
Requires public health services such as surveillance (e.g.,BFRSS), education (AHA, NCEP), organizational partnerships (Singapore Declaration), and legislation/policy (Anti-Tobacco policies)
Activities in a variety of community settings: schools, worksites, churches, healthcare facilities, entire communities

14. A conceptual framework for public health practice in CVD prevention
A conceptual framework for public health practice in CVD prevention. (From Pearson et al., J Public Health. 2001; 29:69 –78)

15. Communitywide CVD Prevention Programs
Stanford 3-Community Study ( ) showed mass media vs. no intervention in high-risk residents to result in 23% reduction in CHD risk score
North Karelia (1972-) showed public education campaign to reduce smoking, fat consumption, blood pressure, and cholesterol
Stanford 5-City Project ( ) showed reductions in smoking, cholesterol, BP, and CHD risk
Minnesota Heart Health Program ( ) showed some increases in physical activity and in women reductions in smoking

16. Materials Developed for US Community Intervention Trials
Mass media, brochures and direct mail
Events and contests
Screenings
Group and direct education
School programs and worksite interventions
Physician and medical setting programs
Grocery store and restaurant projects
Church interventions
Policies

17. Individual and High-Risk Approaches
Primary Prevention Guidelines (1995) and Secondary Prevention Guidelines (Revised 2001) released by the American Heart Association provide advice regarding risk factor assessment, lifestyle modification, and pharmacologic interventions for specific risk factors
Barriers exist in the community and healthcare setting that prevent efficient risk reduction
Surveys of CVD prevention-related services show disappointing results regarding cholesterol-lowering therapy, smoking cessation, and other measures of risk reduction

18. Presentation Examination: Cardiopulmonary exam: normal
Height: 6 ft 2 in
Weight: 220 lb (BMI 28 kg/m2)
Waist circumference: 41 in
BP: 150/88 mm Hg
P: 64 bpm
RR: 12 breaths/min
Cardiopulmonary exam: normal
Laboratory results:
TC: mg/dL
HDL-C: 36 mg/dL
LDL-C: 140 mg/dL
TG: mg/dL
FBS: mg/dL

19. Risk Assessment Count major risk factors
For patients with multiple (2+) risk factors
Perform 10-year risk assessment
For patients with 0–1 risk factor
10 year risk assessment not required
Most patients have 10-year risk <10%

20. ATP III Assessment of CHD Risk
For persons without known CHD, other forms of atherosclerotic disease, or diabetes:
Count the number of risk factors:
Cigarette smoking
Hypertension (BP 140/90 mmHg or on antihypertensive medication)
Low HDL cholesterol (<40 mg/dL)†
Family history of premature CHD
CHD in male first degree relative <55 years
CHD in female first degree relative <65 years
Age (men 45 years; women 55 years)
Use Framingham scoring for persons with 2 risk factors* (or with metabolic syndrome) to determine the absolute 10-year CHD risk. (downloadable risk algorithms at
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:
© 2001, Professional Postgraduate Services®

21. Assessing CHD Risk in Men
ATP III Framingham Risk Scoring
Assessing CHD Risk in Men
Step 1: Age
Years Points
Systolic BP Points Points (mm Hg) if Untreated if Treated
< ³
Step 4: Systolic Blood Pressure
Age
Total cholesterol
HDL-cholesterol
Systolic blood pressure
Smoking status
Point total
Step 6: Adding Up the Points
Step 7: CHD Risk
Point Total 10-Year Risk Point Total 10-Year Risk
<0 <1% 11 8%
0 1% 12 10%
1 1% 13 12%
2 1% 14 16%
3 1% 15 20%
4 1% 16 25%
5 2% ³17 ³30%
6 2%
7 3%
8 4%
9 5%
10 6%
Step 2: Total Cholesterol
TC Points at Points at Points at Points at Points at (mg/dL) Age Age Age Age Age 70-79
< ³
Note: Risk estimates were derived from the experience of the Framingham Heart Study, a predominantly Caucasian population in Massachusetts, USA.
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:
HDL-C (mg/dL) Points
³60 -1
<40 2
Step 3: HDL-Cholesterol
Step 5: Smoking Status
Points at Points at Points at Points at Points at Age Age Age Age Age 70-79
Nonsmoker
Smoker
© 2001, Professional Postgraduate Services®

22. Assessing CHD Risk in Women
ATP III Framingham Risk Scoring
Assessing CHD Risk in Women
Systolic BP Points Points (mm Hg) if Untreated if Treated
< ³
Step 4: Systolic Blood Pressure
Age
Total cholesterol
HDL-cholesterol
Systolic blood pressure
Smoking status
Point total
Step 6: Adding Up the Points
Step 1: Age
Years Points
Step 7: CHD Risk
Point Total 10-Year Risk Point Total 10-Year Risk
<9 <1% 20 11%
9 1% 21 14%
10 1% 22 17%
11 1% 23 22%
12 1% 24 27%
13 2% ³25 ³30%
14 2%
15 3%
16 4%
17 5%
18 6%
19 8%
Step 2: Total Cholesterol
TC Points at Points at Points at Points at Points at (mg/dL) Age Age Age Age Age 70-79
< ³
HDL-C (mg/dL) Points
³60 -1
<40 2
Step 3: HDL-Cholesterol
Note: Risk estimates were derived from the experience of the Framingham Heart Study, a predominantly Caucasian population in Massachusetts, USA.
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:
Step 5: Smoking Status
Points at Points at Points at Points at Points at Age Age Age Age Age 70-79
Nonsmoker
Smoker

23. ATP III Framingham Risk Scoring
Step 1: Age
Men
Years Points
Women
Years Points
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:

24. Step 2: Total Cholesterol
ATP III Framingham Risk Scoring
Step 2: Total Cholesterol
TC Points at Points at Points at Points at Points at (mg/dL) Age Age Age Age Age 70-79
< ³
Men
TC Points at Points at Points at Points at Points at (mg/dL) Age Age Age Age Age 70-79
< ³
Women
Note: TC and HDL-C values should be the average of at least two fasting lipoprotein measurements.
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:

25. Step 3: HDL-Cholesterol
ATP III Framingham Risk Scoring
Step 3: HDL-Cholesterol
Men
Women
HDL-C (mg/dL) Points
³60 -1
<40 2
HDL-C (mg/dL) Points
³60 -1
<40 2
Note: HDL-C and TC values should be the average of at least two fasting lipoprotein measurements.
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:

26. Step 4: Systolic Blood Pressure
ATP III Framingham Risk Scoring
Step 4: Systolic Blood Pressure
Men
Systolic BP Points Points (mm Hg) if Untreated if Treated
< ³
Women
Systolic BP Points Points (mm Hg) if Untreated if Treated
< ³
Note: The average of several BP measurements is needed for an accurate measurement of baseline BP. If an individual is on antihypertensive treatment, extra points are added.
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:

27. Step 5: Smoking Status Men Women
ATP III Framingham Risk Scoring
Men
Points at Points at Points at Points at Points at Age Age Age Age Age 70-79
Nonsmoker
Smoker
Women
Points at Points at Points at Points at Points at Age Age Age Age Age 70-79
Nonsmoker
Smoker
Note: Any cigarette smoking in the past month.
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:

28. Step 6: Adding Up the Points (Sum From Steps 1–5)
ATP III Framingham Risk Scoring
Step 6: Adding Up the Points (Sum From Steps 1–5)
Age
Total cholesterol
HDL-cholesterol
Systolic blood pressure
Smoking status
Point total
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:

29. ATP III Framingham Risk Scoring
Step 7: CHD Risk for Men
Point Total 10-Year Risk Point Total 10-Year Risk
<0 <1% 11 8%
0 1% 12 10%
1 1% 13 12%
2 1% 14 16%
3 1% 15 20%
4 1% 16 25%
5 2% ³17 ³30%
6 2%
7 3%
8 4%
9 5%
10 6%
Note: Determine the 10-year absolute risk for hard CHD (MI and coronary death) from point total.
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:

30. What is WJC’s 10-year absolute risk of fatal/nonfatal MI?
A 12% absolute risk is derived from points assigned in Framingham Risk Scoring to:
Age: 6
TC: 3
HDL-C: 2
SBP: 2
Total: points
In 1992 he exercised 14 minutes in a Bruce protocol exercise stress test to 91% of his maximum predicted heart rate without any abnormal ECG changes. He started on a statin in But in Sept 2004, he needed urgent coronary bypass surgery.

31. Step 7: CHD Risk for Women
ATP III Framingham Risk Scoring
Step 7: CHD Risk for Women
Point Total 10-Year Risk Point Total 10-Year Risk
<9 <1% 20 11%
9 1% 21 14%
10 1% 22 17%
11 1% 23 22%
12 1% 24 27%
13 2% ³25 ³30%
14 2%
15 3%
16 4%
17 5%
18 6%
19 8%
Note: Determine the 10-year absolute risk for hard CHD (MI and coronary death) from point total.
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:

32. CHD Risk Equivalents
Risk for major coronary events equal to that in established CHD
10-year risk for hard CHD >20%
Hard CHD = myocardial infarction + coronary death

33. Diabetes as a CHD Risk Equivalent
10-year risk for CHD  20%
High mortality with established CHD
High mortality with acute MI
High mortality post acute MI

34. CHD Risk Equivalents
Other clinical forms of atherosclerotic disease (peripheral arterial disease, abdominal aortic aneurysm, and symptomatic carotid artery disease)
Diabetes
Multiple risk factors that confer a year risk for CHD >20%