Epidemiology of Coronary

Heart Diseases
 Cardiovascular diseases
 Cardiovascular disease is caused by disorders of the heart
and blood vessels, and includes coronary heart disease
(heart attacks), cerebrovascular disease (stroke), raised
blood pressure (hypertension), peripheral artery disease,
rheumatic heart disease, congenital heart disease and heart
failure.
 Although heart attacks and strokes are major killers in all
parts of the world, 80% of premature deaths from these
causes could be avoided by controlling the main risk
factors: tobacco, unhealthy diet and physical inactivity.
• Cardiovascular disease is responsible for 10% of
DALYs(Disability-adjusted life years) lost in low- and
middle-income countries, and 18% in high income
countries. More than 60% of the global burden of
coronary heart disease occurs in developing countries.
Coronary heart disease (CHD) is the most common form
of heart disease and the single most important cause of
premature death in Europe, the Baltic states, Russia,
North and South America, Australia and New Zealand.
By 2020 it is estimated that it will be the major cause of
death in all regions of the world.
• In the UK (population 59 million), 1 in 3 men and 1 in 4
women die from CHD, an estimated 330 000 people
have a myocardial infarct each year and approximately
1.3 million people have angina.
 The epidemiological observations about CHD
1. Large population differences in CHD incidence & mortality
rate.
2. Strong correlation between differences in CHD rates &
population differences in mean level & distribution of risk
factors.
3. Within population, strong & continuous correlation between
several risk factors(S. cholesterol, B.P, Smoking…etc.) &
future risk of CHD.
4. Packing of CHD risk factors among children into adulthood.
5. Incidence & risk factors of CHD in migrants rapidly approach
level of adopted population i.e. largely depend on
environmental factors.
.
6.The decline in CHD mortality rate seen in industrialized countries
include all ages, both sexes, & all races. Low- and middle-
income countries are disproportionally affected: 82% of CVD
deaths take place in low- and middle-income countries and
occur almost equally in men and women.
7.The above decline is associated with decline in death rate from
stroke.
8.Randomize control trial found direct effect of decrease in risk
factors on subsequent disease rate . prospective studies found
that established RF & associated health behavior can be safely
modified.
9. Epidemiological evidence is consistent with clinical & laboratory
finding about causes & mechanism of atherosclerosis which
underlies the manifestation of CHD.
Pathogenesis
• The development of CHD involving two stages:
1. the acute occlusive events due to formation
of blood clot leading to clinical events.

2. long term formation of atherosclerosis of the

artery wall, begin even at adolescence.
Manifestations of
CHD
 :

1.Angina Pectoris:
• It is the major cause of disability from the 4thdecade &
onward.
• The diagnosis is subjective with no gold standard test to DX
2.Myocardial infarction:
50% of MI cases are either atypical , missed, or misdiagnosed
as seen by ECG surveys . 
The following factors were found to improve survival:
• Prevention of ventricular fibrillation early in the attack.
• Initial treatment with aspirin or thrombolytic agents.
• Long-term treatment with aspirin, b-blockers, ACEIs.
• Avoidance of smoking.
• Rehabilitation: exercise & diet
• Cholesterol lowering treatment.
3. Sudden Death: 
• Definitions are variable from immediate death to death
within 5min, 1hr, 3hrs, 12hrs, & 24hrs.
• 70% of deaths occur outside the hospitals, this lead to
development of mobile CCU, paramedical services, &
population training program in resuscitation.
• 20%-40% of potential coronary death had no history of
symptoms or autopsy finding of any DX.
• Autopsy studies found that sudden death could be due to
pneumonia, valvular heart disease, drug or alcohol
overuse 50% of all death occurring during acute stage of
sever chest pain within 2hrs of onset & mostly within few
minutes
4. Chronic heart failure & LV dysfunction:
• It account for small proportion of death, but
increasing due to increase aging & increase
survival from CHD. It follow history of MI or
myocardial ischemia at many occasions.
• Admission from HF increase with increase age
& DM. It is a significant contribute to hospital
cost.
• ACEIs are beneficial in increasing survival rate
 Interrelationship of various manifestations
 One type of CHD increase risk of others.
 20% of CHD victims' have sudden death as a first
manifestation.
 >50% of MI had history of angina.
 MI on exercise test after MI indicate high risk of death or
reinfarction.
 Women have lower rates of sudden death or MI than men but
have almost similar rates of angina.
 Women have lower rates of CHD mortality than men.
 Those with previous history of CHD have good prognosis than
those who are not.(-ve HX). The more severe & persistent
symptoms, the greater risk of major coronary events(MI,
Sudden death).& the greater number of indicators of
myocardial ischemia, mean the more advanced disease &
worse prognosis
Diagnosis
The most important diagnostic measures
• 1.Resting ECG(not sensitive)
• 2. Dynamic electrocardiogram (Holter monitoring). This test is the
ambulatory recording of an ECG, for a longer period of time (24–
48 hours), to determine whether there are transient problem.
• 3.Resting echocardiogram.
• 4.Exercise ECG: exercise tolerance test (ETT)
• 5. Stress echocardiography(by exercise or drugs).
• 6. Coronary arteriography.
• 7. Myocardial perfusion scanning(by using radioactive substance)
• 8. An electrophysiology study.
•  
Risk factors
• The overall risk of having a heart attack is much
higher if a person has several risk factors. Risk
factors multiply each other’s effect of increasing the
risk of coronary heart disease. The etiology of CHD is
multifactorial. It is the result of interaction between
genetic, lifestyle and environmental factors.
• Risk factors that cannot be changed include:
1. Age: CHD increases with age. This is a non-
modifiable risk factor
• 2. Gender
• Traditionally, CHD has been considered a disease of
men(RR is tow in males). However, CHD is the leading
cause of death in both men and women.
• 3. Family history
• First degree relatives of patients with premature
myocardial infarction have double the risk themselves.
• Premature coronary heart disease is that before 55
years in men and 60 years in women.
• Genetic predisposition and shared lifestyle are likely to
contribute
4. Ethnicity
• South Asians living in the UK (people from India, Pakistan,
Bangladesh and Sri Lanka) have a higher premature death
rate from CHD (46% higher for men; 51% higher for
women). Hypotheses for this include migration,
disadvantaged socioeconomic status, 'proatherogenic
diet', lack of exercise, high levels of homocysteine and
LP(a) lipoprotein, endothelial dysfunction and enhanced
plaque and systemic inflammation.
• The premature death rate from CHD in West Africans and
people from the Caribbean is much lower (half the rate
compared to the general population for men and two-
thirds of the rate for women).
• Modifiable risk factors include:
• 1.Smoking
• Mortality from CHD is 60% higher in smokers.
• Regular exposure to passive smoking increases CHD
risk by 25%.
• WHO research estimates that over 20% of CVD is due
to smoking. The risk of coronary heart disease is 2–4
times higher among smokers than among nonsmokers.

 
2.Poor nutrition
• A World Health Organization report in 2003 stated that a diet
high in fat (particularly saturated fat), sodium and sugar and
low in complex carbohydrates, fruit and vegetables increases
the risk of cardiovascular disease.
• FDI recommended that the percentage food energy derived
from fat should be 35%, with 11% from saturated fat.
• The Scientific Advisory Committee on Nutrition suggests that
salt intake should be no more than 6g per day.
• Eating oily fish rich in omega-3 fatty acids has been shown to
reduce CHD mortality.
• Increased intake in dietary fiber also appears to reduce risk
 3.Infrequent exercise (Sedentary lifestyle)
• The 2002 World Health Report estimated that over 20%
of CHD in developed countries was due to physical
inactivity.
• Recommended physical activity levels are 30 minutes of
moderate physical activity on 5 or more days per week.
4.Alcohol

• The World Health Report in 2002 estimated that 2% of

CHD in men in developed countries is due to excessive
alcohol consumption
 5.Psychosocial wellbeing(stress)
• Work stress, lack of social support, depression, anxiety
and personality (particularly hostility) can all increase
CHD risk.
• 6.Blood pressure
• For adults aged 40 to 69 years, each 20 mmHg rise in
usual systolic blood pressure or 10 mmHg rise in
diastolic blood pressure doubles the risk of death from
CHD.
• The INTERHEART study showed that 22% of heart
attacks in Western Europe were due to a history of high
blood pressure and those with hypertension had almost
twice the risk of a heart attack.
• 7.Cholesterol(dyslipidemia):
• CHD risk is related to cholesterol levels. Cholesterol is the
main ingredient of atherosclerotic plaque.
• The INTERHEART study suggested that 45% of heart attacks
in Western Europe are due to abnormal blood lipids.
• People with low levels of HDL-cholesterol have an
increased risk of CHD and a worse prognosis after a
myocardial infarction.
• In the UK, it is suggested that the target cholesterol is < 4
mmol/l for people with diabetes or established CVD or for
people at high risk of developing CVD. People with HDL-
cholesterol < 1 mmol/l should also be considered for
treatment.
8.Overweight and obesity
• Obesity is an independent risk factor for CHD. It is
also a risk factor for hypertension, hyperlipidaemia,
diabetes and impaired glucose tolerance.
• Central or abdominal obesity is most significant.
Those with central obesity have over twice the risk
of heart attack.
9.Diabetes
• Men with Type 2 diabetes have a 2 to 4 times
greater annual risk of CHD; women have a 3 to 5
times greater risk.
 10.Serum homocysteine
• It was previously thought that elevated levels of homocysteine is
an independent risk factor for IHD, likely to due oxidative damage
to endothelium, platelet activation and thrombus formation. The
theory was that dietary supplementation with folic acid could
reduce homocysteine levels and therefore CHD incidence.
11.socioeconomic status: in developed countries inverse
association, while in developing positive association.
• The presence of one risk factor implies that the atherogenic risk
is 1 on a relative scale.
• The presence of three risk factors implies that the relative
atherogenic risk is 9 and not 3, because the risk does not grow
arithmetically (1 + 1 + 1= 3) but exponentially(3 times 3 = 9).
Conversely, eliminating two of three risk factors would reduce the
relative atherogenic risk from 9 to 1.
Prevention
• Primordial prevention:
1.national policies & programs on food& nutrition.
2.comperhensive policy to discourage smoking.
3.Programs for the prevention of hypertension.
4.programs to promote regular exercise.
• the strategy is to introduce population wide
intervention to lower the population level of
obesity, smoking, saturated fatty consumption &
salt intake. The strategy is to maintain health
promoting diet & socioeconomic conditions
which support non-smoking & active life style.
 Specific actions:
A. Tobacco control: by
1.Political commitment & support.
2.Special emphasis on the control among women,
children, & adolescents.
3. Effective health education.
4.Legislations & implementation of these Legislations.
5.Role model by health professional & school teacher.
6.Strengthening of cultural & religious values against
smoking
• Examples of legislations:
Prohibit smoking in public places, school, &
health care facilities & selling cigarette to
children.
Appropriate warning labels.
prohibition tobacco advertisement &
promotion.
Prevention new investments in the
development of tobacco industry.
Increase taxation on tobacco products
• B. Physical activity:
Activities should be feasible & could be
incorporated on the daily life.
Encourage sports activity at school & work places.
Formulation & use of simple guideline on physical
exercises.
Changing the misconception of both women &
community about obesity through heath education.
C. Nutrition & dietary modification:
• It should cover all aspects of food changes from production to
consumption, so multisectorial collaboration is
essential(agriculture, trade, industry, education & health)
• Health education & specific legislation are basic components.
Dietary guideline:
• A balanced intake of calories.
• Reduced salt content of the diet.
• Reduced total saturated fat intake.
• Rise consumption of fruit & vegetables.
• Prevention of unhealthy diet habits & stopping invasion of
fast-food.
It is necessary to strengthen the role of school health curriculum
which should cover the knowledge & attitude needed for CVD
prevention.