Community Medicine Department Faculty of Medicine University of Indonesia

SETYAWATI BUDININGSIH, RETNO ASTI WERDHANI

May 3rd. 2010

DESCRIPTIVE EPIDEMIOLOGY

Incidence Prevalence

Holistic Diagnosis (BIOPSYCHOSOSIAL)

Risk Factors

Diagnostic Tools

ANALYTIC EPIDEMIOLOGY

Therapy, Prognosis CLINICAL EPIDEMIOLOGY (Prognostic Study, Clinical Trial, Meta Analysis)

Triad Epidemiology Host Agent - Environment

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.

The major causes of cardiovascular disease are tobacco use, physical inactivity, and an unhealthy diet.

Predispose factors : Age, Gender, Family history, Behavior,

Sanitation, etc

Clinical Risk factors : Obesity/Malnourished, Hypertension

Dyslipidemia, Impairment of Glucose Control, and Systemic Inflammation, etc

Smoking raises risk of atherosclerotic disease and potentiates myocardial infarction (MI)

Smoking cessation reduces the risk of MI and mortality by 36%

Smoking cessation : education about the danger of smoking and intervention with nicotine replacement and bupropion

Relapse rate are high in the absence of education and encouragement.

Hypertension Atherosclerotic Coronary Heart Disease and

Peripheral Vascular Disease Congestive Heart Failure Congenital Heart Disease Valvular Health Disease Cardiac Arrhythmias

SKRT 2001 6 % HTN at 25-34 yr 15 % HTN at 35-44 yr 43 % HTN at > 55 yr 2/3 uncontrolled HTN patients at > 60 yr will have

CHD, MCI, or Stroke within 5 year

Risk of HTN is regulated by genetic background and environmental factors

For every 20/10 mmHg increase BP above 115/75 mmHg, risk of CVD doubles (Chobanian et al, 2003)

Prevalensi hipertensi pada penduduk umur 18 tahun ke atas di Indonesia adalah sebesar 31.7 %

Prevalensi stroke di Indonesia adalah 8.3 per 1000 penduduk

JAMA. 1990;263:1795-1801

The reduction of BP, reduces risk of acute cardiovascular events, progression of atherosclerosis, and end organ injury

5 mmHg SBP reduction reduces 14 % stroke death and 9 % CVD death (Chobanian et al, 2003)

2 mmHg DBP reduction has benefit for prevention (Cook NR, 1996)

Atherosclerosis begins in childhood and evolves over decades (Freedman et al, 1988), affecting > 85% adults > 50yr old (Tuzcu et al, 2001)

Causes Coronary Artery Disease (CAD) and Peripheral Vascular Disease (PVD)

Risk factors : Dyslipidemia, Hypertension, Impairment of Glucose Control, Age, family history, smoking, obesity, and systemic inflammation

High HDL level reduce the risk of developing CAD (Toth, 2001)

Patients with familial low HDL have increase risk of premature CAD (Toth, 2003)

Patients with familial high HDL are relatively resistant to CAD (Toth, 2004)

The more elevated level of HDL, the lower the risk for CAD

Risk factors for CAD Negative : HDL > 60 mg/dl Positive : Cigarette smoking HDL < 40 mg/dl (men), < 50 mg/dl (women) BP > 140 / > 90 (or use of antihypertensive agents) Family history of premature CAD (CAD in male first

degree relative < 55 yr; CAD in female first degree relative < 65yr)

Age (men >=45 yr; women >=55 yr)

Risk Assessment Tool for Estimating 10-year Risk of Developing Hard Coronary Heart Disease (Myocardial Infarction and Coronary Death) The risk assessment tool below uses recent data from the Framingham Heart Study to estimate 10-year risk for hard coronary heart disease outcomes (myocardial infarction and coronary death). This tool is designed to estimate risk in adults aged 20 and older who do not have heart disease or diabetes. Use the calculator below to estimate 10-year risk.

Age: years Gender: Female Male

Total Cholesterol: mg/dL

HDL Cholesterol: mg/dL Smoker: No Yes

Systolic Blood Pressure: mm/Hg Currently on any medication to treat high blood pressure. No Yes

35

46

190

110

CVD Diabetes

Hypertension

Dyslipidemia Low HDL, high TG

Hyperglycemia

Hypercoagulability Impaired fibrinolysis

Endothelial dysfunction

Change in Adipose

hormones

Birth size, Childhood

growth

Hyperuricemia

Systemic inflammation

Socioeconomic status

Physical Inactivity

Genetic predisposition Diet

Abdominal obesity, Ectopic fat deposition

Insulin Resistance

The Metabolic Syndrome

Textbook of Family Medicine, Rakel, 07

The incidence of Metabolic Syndrome increases in men and women as a function of age (Ford et al 2002, Alexander et al 2003)

Patients with Metabolic Syndrome had 3.77 fold increase in risk of CVD mortality compared to patients without it (Lakka et al 2002)

Patients who have ANY THREE (3) of five risk factors meet criteria for the metabolic syndrome

Risk Factor Defining Level Abdominal obesity Men : Waist > 90 cm

Women : Waist > 80 cm Triglycerides >=150 mg/dl HDL Men : < 40 mg/dl

Women : < 50 mg/dl Blood Pressure >=130 / >=85 mmHg Fasting Glucose >=100 mg/dl

A clinical syndrome resulting from the inability of the heart to meet metabolic requirements of the body at normal filling measure

Patient with CHF should have their CVD risk factors controlled aggressively

Target BP for CHF patients

An illness of children and adolescents with the average age of onset 8-10 yr

Associated with pharyngitis, caries dentis (bad oral hygiene), poverty, crowded living conditions, and difference in access to or utilization of medical care

Nepal : High rates of RHD may not relate to increased prevalence of streptococcal infection, but to inadequate antibiotic therapy (proper dosage and duration) of streptococcal pharyngitis.

Philippines: giving penicillin to school children with pharyngitis (prior to confirmation of its etiology), can reduce the attack rate of rheumatic fever by ten folds.

Patients with established cardiac complications must be regularly followed-up.

This requires cooperation and understanding of prognosis by patients and relatives and counseling on the doctors part

Ventricular Septal Defect Atrial Septal Defect Tetralogy Fallot Pulmonary Stenosis Patent Ductus Arteriosus Idiopathic Pulmonary Artery Dilatation Dextrocardia Hipertensi Pulmonal Primum. Lain-lain

Only 1% of the children with congenital heart disease are today properly treated in Indonesia.

The lack of the information and education on the part of the patients

Uneven distribution of doctors A shortage of pediatrician A shortage of funding, both privately and

publicly Number of cardiac surgery hospital

**Resource: WHO and World Bank 2005

CARDIOVASCULARDISEASES

CANCER

CHRONICRESPIRATORY

DISEASE

DIABETES

17.528.000

7.586.000

4.057.000

1.125.000

MALARIA

TUBERCULOSISHIV/AIDS

2.830.000

WHO Statistics 2007

Age-standardized CVD mortality rate per 100.000 population (2002)

0 100 200 300 400 500

United States

United Kingdom

India

Jepang

Indonesia

Filipina

Vietnam

Timor Leste

CO

UN

TRIE

S

MORTALITY RATE

mortality

Thailand

Singapore

Malaysia

China

Srilanka

Australia

Canada

WHO Statistics 2007

441

171 336

274 361

291 106

314 428

140 182

141 188

318 199

HOST : Characteristic :

Age, Gender, Behavior,

etc

ENVIRONMENT : Family, Occupation,

Housing, Sanitation, etc

AGENT : Lipid, Glucose, Bacterial, etc

DISEASE OCCURANCE : TRIAD EPIDEMIOLOGY

Pharmacology Drugs

Non Pharmacology (health education/ counseling) on : Diet, Exercise, Smoking Cessation, Drugs compliance

Individual Perceptions

Perceived susceptibility/

Severity of disease

Cues to action : Education,

Symptom, illness Media Information

Perceived threat of disease

Age, gender, ethnicity, Personality,

Socioeconomics, Knowledge

Modifying Factors

Likelihood of Behavior change

Perceived benefits Minus perceived

Barriers to behavior change

Likelihood of Action

Health Behavior and Health Education, Glanz et al, 1997

Promotion Prevention Surveillance and Early Treatment

Social Determinants (Culture, Economy,

Finance)

Promotion and Prevention

A man, 58 years old, sees his family doctor because of chest pain. He had been well until 2 weeks ago, when he noticed tightness in the center of his chest when he was walking uphill.

Remember Risk Factors (Biopsychosocial)

58

Died 60 of CVD

Died ? of DM

Due to lots of contributing factors and broad-integrated disease management :

Continuing care and monitoring are important to provide good health services for cardiovascular disease

Educational approach and family participation are needed for : Patient to cope with the disease Getting patient and familys independence

for improving/maintaining health status

Menanggulangi kemiskinan dan kelaparan Mencapai pendidikan dasar untuk semua Mendorong kesetaraan gender dan pemberdayaan

perempuan Menurunkan angka kematian anak Meningkatkan kesehatan ibu Memerangi HIV/AIDS, malaria, dan penyakit

menular lainnya Memastikan kelestarian lingkungan hidup

Riskesdas 2007 Profil Kesehatan Indonesia 2005 www. americanheart.org Toth PP, et al: Cardiovascular Disease. In: Rakel RE, et all (ed):

Textbook of Family Medicine, 7th ed. Philadelphia, Saunders Elsevier, 2007:735-805

Branch WT, et al (ed): Cardiology in Primary Care, Intl ed. New York, McGraw-Hill, 2000

Fletcher RH, et al: Clinical Epidemiology the essentials, 2nd ed. Baltimore,Williams & Wilkins, 1988

Glanz K, et al: Health Behavior and Health Education, 2nd ed. San Francisco, Jossey-Bass Publishers, 1997

Affandi M. Penyakit Jantung Bawaan: Apa yang harus dilakukan?. Cermin Dunia Kedokteran no 31

A Ibrahim, et all. Rheumatic Heart Disease: How Big is the Problem?. Med J Malaysia vol 50 no 2 June 1995

Balaban DJ: Epidemiology and Prevention of Selected Chronic Illnesses. In: Cassens BJ (ed): Preventive Medicine and Public Health, 2nd ed. Philadelphia, Harwal Publishing,1992:135-138