1. Epidemic of Cardiovascular disease Global and US trends Any Lessons for Honduras? Dr. Thomas G. Allison Cardiovascular Diseases and Internal Medicine Mayo Clinic Rochester, MN

2. Disclosures Conflicts of interest: none Off-label use of drugs or devices: none

3. Global Burden of Cardiovascular Disease Developing countries 80% of worldwide CV deaths Occur at a younger age 2010 – 70% of the elderly will live in the developing world Total deaths – 57 million Cardiovascular 16.7 million HIV TB Malaria HIV TB Malaria 5 million Lopez. Lancet 2006; Reddy. NEJM 2004 2002 statistics

4. International Comparison (Men ages 35-74)

5. Cardiovascular Disease in the Americas

7. Highest Lowest

8. Life Expectancy in the Americas Haiti: 55 years Guyana: 63 years Bolivia: 65 years Honduras: 67 years Brazil: 70 years Peru: 71 years Jamaica: 72 years Paraguay: 72 years Columbia: 73 years Mexico: 74 years Argentina: 75 years Uruguay: 75 years Panama: 76 years Costa Rica: 77 years Chile: 77 years Cuba: 78 years USA: 78 years Canada: 80 years

9. Modified Model of the Epidemiological Transition as it Pertains to Cardiovascular Disease Yusef et al. Circulation 2001;104:276-2753

10. Stage 1: Age of Pestilence and Famine Life expectancy< 55 years CVD deaths5-10% of total deaths < 5% of years of life lost (YLL) Prominent CV diseases and risk factors Rheumatic heart disease, infections, nutritional cardiomyopathies Regional examplesSub-Saharan Africa, rural India, Haiti

11. Stage 1: Haiti Life expectancy = 55 years

12. Causes of Death Haiti 2002 Cause of DeathDeathsYLL HIV/AIDS22%20% Lower respiratory infections7%9% Cerebrovascular disease6%3% Meningitis5%7% Diarrheal diseases5%7% Perinatal conditions4%7% Tuberculosis4% Hypertensive heart disease3%1% Anemia3%4% Diabetes mellitus3%1%

13. Stage 2: Age of Receding Pandemics Life expectancy55-65 years CVD deaths10-35% of total deaths Prominent CV diseases and risk factors Rheumatic heart disease, infections, nutritional cardiomyopathies, hypertensive heart disease, hemorrhagic strokes Regional examplesSoutheast Asia, rural China, Central and South America, Bolivia

14. Stage 2: Bolivia Life expectancy = 65 years

15. Causes of Death Bolivia 2002 Cause of DeathDeathsYLL Lower respiratory infections9%12% Perinatal conditions8%14% Diarrheal diseases6%10% Ischemic heart disease5%2% Cerebrovascular disease4%2% Tuberculosis4% Cirrhosis of the liver3%2% Nephritis and nephrosis3%2% Cervix and uterine cancers*2% Diabetes mellitus2%1%

16. Stage 3: Age of Degenerative and Man-Made Diseases Life expectancy65-75 years CVD deaths35-65% of total deaths Prominent CV diseases and risk factors All forms of stroke, ischemic heart disease at young ages, increasing obesity and diabetes Regional examplesEastern Europe, China, urban India, Non-Hispanic Caribbean, Jamaica

17. Stage 3: Jamaica Life expectancy = 72 years

18. Causes of Death Jamaica 2002 Cause of DeathDeathsYLL Cerebrovascular disease18%11% Diabetes mellitus11%8% Ischemic heart disease10%6% Hypertensive heart disease6%4% Lower respiratory infections4% HIV/AIDS4%9% Stomach cancer3%2% Nephritis and nephrosis3% Perinatal conditions2%8% Breast cancer2%3%

19. Yang. Lancet, 2008 Changing Distribution of the Causes of Death in Peoples Republic of China Proportion of deaths (%) Year Unknown Injury Other non-communicable diseases Chronic obstructive pulmonary disease Cerebro-cardiovascular disease Cancer Maternal and perinatal conditions Communicable diseases Unknown Injury Other non-communicable diseases Chronic obstructive pulmonary disease Cerebro-cardiovascular disease Cancer Maternal and perinatal conditions Communicable diseases

21. Stage 4: Age of Delayed Degenerative Diseases Life expectancy> 75 years CVD deaths50% of total deaths Prominent CV diseases and risk factors Stroke and ischemic heart disease at old age Regional examples Western Europe, Australia and New Zealand, North America, USA

22. Causes of Death USA 2002 Cause of DeathDeathsYLL Ischemic heart disease21%15% Cerebrovascular disease7%4% Trachea, bronchus, lung cancers7% Chronic obstructive pulmonary disease5%4% Alzheimer and other dementias4%1% Diabetes mellitus3% Colon and rectum cancers3% Lower respiratory infections3%2% Breast cancer2% Road traffic accidents2%6%

24. Age-adjusted US CVD Disease Trends Nemetz et al. Arch Intern Med 2008;163:264-270 Despite decrease in Heart Disease Mortality Heart disease remains highly prevalent #1 Cause of death in US #1 Contributor to US health care costs Years 1996-2004

25. Hospital discharges for cardiovascular diseases. (United States: 1970-2006). Note: Hospital discharges include people discharged alive, dead and status unknown. Source: NCHS and NHLBI.

26. Estimated direct and indirect costs (in billions of dollars) of major cardiovascular diseases and stroke (United States: 2009). Source: NHLBI. Total Cost = 344.9 billion dollars

27. Transition Factors 1 → 2 Sanitation – water quality Immunization Antibiotics Population growth Older population Increased mechanization of food production More processed food Increased salt intake Hypertension Hypertensive heart disease Hemorrhagic stroke

28. Transition Factors 2 → 3 Changing economy Affluence Mass media Cigarette smoking Reduced physical activity Increased caloric intake More meat consumption Obesity Diabetes Hyperlipidemia Ischemic Stroke MI

29. Incubation Period for Chronic Disease

30. Transition Factors 3 → 4 More educated public Increased spending on medical care Secondary prevention practices Primary prevention practices Improved survival from MI Reduced MI, stroke at young ages

31. CHD Trends McGovern et al, Circulation 2001;104:19-24

32. Reduction in CVD Death Rate in US Pre-1985 due largely to lifestyle changes Smoking cessation 59%  25% Decreased dietary fat intake Increased leisure-time physical activity Post-1985 due largely to medical management Coronary care units Electrical defibrillators Thrombolysis Emergent angioplasty Medical Rx –Aspirin, beta-blockers, ACE-inhibitors, statins McGovern et al. Circulation 2001;104:19-24 [Primary Prevention] [Secondary Prevention]

33. CAD Prevalence in Patients Who Died of Unnatural Causes in Olmsted County, MN and Had Autopsy Nemetz et al. Arch Intern Med 2008;168:264-270

34. Causes of Death Honduras versus US Where is Honduras in the Epidemiologic Transition? Source: Death and Daly estimates by cause, 2002 http://www.who.int/entity/healthinfo/statistics/bodfbddeathdalyestimates.xls

35. Causes of Death Honduras 2002 Cause of DeathDeathsYLL Ischemic heart disease11%4% HIV/AIDS9%14% Perinatal conditions7%13% Cerebrovascular disease5%3% Diabetes mellitus4%2% Diarrheal diseases4%7% Lower respiratory infections4%5% Nephritis and nephrosis4%2% Hypertensive heart disease3%1% Protein-energy malnutrition3%5%

36. Honduras versus US Statistics Life expectancy at birth –Honduras: M = 67/F = 73 US: M = 75/F = 80 Healthy life expectancy at birth –Honduras: M = 56/F = 61US: M = 67/F = 71 Probability of dying between 15-60 years –Honduras: M = 22.9%/F = 13.3% –US: M = 13.7%/F = 8.0%

37. Honduras versus US Statistics Total expenditure on health per capita –Honduras: $241US: $6,714 Gross national income per capita –Honduras: $3,240US: $44,070 Total expenditure on health as % of GDP –Honduras: 7.4% US: 15.3% World Health Statistics 2008 Financial data from 2006

38. Risk Factors in Honduras No data on hyperlipidemia for Honduras Hypertension highly prevalent throughout Latin American and Caribbean –No specific figures for Honduras –Greater for persons of African descent 1 survey on diabetes in Tegucigalpa –Prevalence 7.8%; 42% unrecognized 1 survey 2005-6 on females aged 15-49 for tobacco use and obesity –Urban > rural for both Tobacco use 3.7 versus 0.6% Obesity 23 versus 14%

39. Risk Factors, Honduras

41. Conclusions Honduras is moving into the age of man- made and degenerative diseases All risk factors will be increasing Honduras may not afford US high-tech strategies for CVD prevention

42. In US we treat coronary disease with devices $26,000 USD $5,000 USD $93,000 USD

43. Some less expensive devices to treat coronary disease $19.95 USD $8.09 USD $5.95 USD

44. Greetings from Rochester, MN (winter)

45. Comments? Questions?