اپیدمیولوژی بیماری های قلبی عروقی در ایران و جهان
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اپیدمیولوژی بیماری های قلبی عروقی در ایران و جهان. دکتر اکبر نیک پژوه متخصص طب پیشگیری و پشکی اجتماعی مرکز آموزشی، تحقیقاتی و درمانی قلب و عروق شهید رجایی 1392/10/21 اولین مدرسه زمستانی اپیدمیولوژی. تعریف اپیدمیولوژی. - PowerPoint PPT PresentationTRANSCRIPT
ا�پ�ی�د�م�ی�و�ل�و�ژ�ی� ب�ی�م�ا�ر�ی� ه�ا�ی� ق�ل�ب�ی� ع�ر�و�ق�ی� د�ر� ا�ی�ر�ا�ن� و� ج�ه�ا�ن
پ�ژ�و�ه ن�ی�ک� ا�ک�ب�ر� د�ک�ت�ر�ا�ج�ت�م�ا�ع�ی پ�ش�ک�ی� و� پ�ی�ش�گ�ی�ر�ی� ط�ب� م�ت�خ�ص�ص�
ر�ج�ا�ی�ی ش�ه�ی�د� ع�ر�و�ق� و� ق�ل�ب� د�ر�م�ا�ن�ی� و� ت�ح�ق�ی�ق�ا�ت�ی� آ�م�و�ز�ش�ی�،� م�ر�ک�ز�
1392/10/21ا�پ�ی�د�م�ی�و�ل�و�ژ�ی ز�م�س�ت�ا�ن�ی� م�د�ر�س�ه� ا�و�ل�ی�ن�
ک�ن�ن�د�ه� ت�ع�ی�ی�ن� ع�و�ا�م�ل� و� ت�و�ز�ی�ع� م�ط�ا�ل�ع�ه� ا�ز� ا�س�ت� ع�ب�ا�ر�ت� ا�پ�ی�د�م�ی�و�ل�و�ژ�ی�ب�ه� و� م�ع�ی�ن� ج�م�ع�ی�ت�ه�ا�ی� د�ر� س�ال�م�ت�ی� ب�ا� م�ر�ت�ب�ط� پ�ی�ش�ا�م�د�ه�ا�ی� ی�ا� و� ح�ا�ال�ت�
ب�ه�د�ا�ش�ت�ی م�ش�ک�ال�ت� ب�ا� م�ب�ا�ر�ز�ه� ب�ر�ا�ی� م�ط�ا�ل�ع�ه� ا�ی�ن� ک�ا�ر�گ�ی�ر�ی�
ا�پ�ی�د�م�ی�و�ل�و�ژ�ی ت�ع�ر�ی�ف�
ه�ا�ی� ب�ی�م�ا�ر�ی� ج�ه�ا�ن�ی� ب�ه�د�ا�ش�ت� س�ا�ز�م�ا�ن� گ�ز�ا�ر�ش�ه�ا�ی� ا�ز� ی�ک�ی� ب�ر�ا�س�ا�س�ز�ی�ر�ا�س�ت- ا�خ�ت�ال�ال�ت� م�ج�م�و�ع�ه� ش�ا�م�ل� ع�ر�و�ق�ی� :ق�ل�ب�ی�
•Hypertension (high blood pressure)• Coronary heart disease (heart attack)• Cerebrovascular disease (stroke)• Peripheral vascular disease• Heart failure• Rheumatic heart disease• Congenital heart disease• Cardiomyopathies• Deep vein thrombosis and pulmonary embolism
ع�ر�و�ق�ی ق�ل�ب�ی� ب�ی�م�ا�ر�ی�ه�ا�ی� ت�ع�ر�ی�ف�
پ�ی�ش�گ�ف�ت�ا�ر
hέΎϤϴΑ nήϣϭ ϧϮΗΎϧϞϣΎϋϦҨήΘϤϬϣ ϗϭήϋ -ΒϠϗh Ύϫ ίζ ϴΑ)α έΩϭίh Ύϫ1/17n ήϣϥϮϴϠϴϣ-ϪϧϻΎγ2010ϪϨҨΰϫϦϴϨ Ϥϫϭ ( ϣέΎϤη ϪΑϥΎϬΟήγ ήγ έΩΖ ϣϼγ ϡΎψϧΖ ϔ� Ϩϫh Ύϫ .Ϊ ϧϭέ
ϣήΑβ ҨίϭήϠγ ϭήΗϩΪ ҨΪ� ϪΑϊ ϗ ϭέΩh έΎϤϴΑϦҨ γ ΎϨη ΐ ϴγ h ΩΎϤΘϣϥΎϴϟΎγ ρϪ ΩΩή¥ϣΖ ϓήθ ϴ �ϪϠΣήϣϪΑϟΎδ ϧΎϴϣέΩΎ˱ΗΪ Ϥϋ ϨόҨˬϢϼϋ ίϭήΑϡΎ �Ϩϫ ϻ˱ϮϤόϣϭϩΪ ϣΩϮΟϮΑ .Ϊ γ έ
پ�ی�ش�گ�ف�ت�ا�ر
ϝ Ύγ ϦϴΑϪ ΩϮη ϣ ϨϴΑζ ϴ� h Ύϫ2006ΎΗ2015Ϫ ήϴ¥ ϭήϴϏh ΎϬҨέΎϤϴΑί n ήϣϥ ΰϴϣϣι ΎμΘΧΩϮΧϪΑ ϗϭήϋ - ΒϠϗh Ύϫh έΎϤϴΑ έϥί Ϥϴϧ ϪΑˬΪ ϫΩ71Ϫ ϴϟΎΣέΩˬΪ γ ήΑ %
ϪҨάϐΗΕ ϻϼΘΧϭ ϧϮϔϋh Ύϫh έΎϤϴΑί n ήϣ Ζ ϓΎҨΪ ϫ ϮΧζ ϫΎϥ ΩίϮϧϭϥ έΩΎϣήϴϣϭn ήϣϭh
پ�ی�ش�گ�ف�ت�ا�ر
έΩϭ ΘόϨλ h ήϬη ϊ ϣ ϮΟέΩϥ ΩήϣϭϥΎϧίήϴϣϭn ήϣΖ ϠϋϦϴϟϭ ϗϭήϋ -ΒϠϗh Ύϫh έΎϤϴΑΖ Ϡϋ ϗϭήϋ - ΒϠϗh Ύϫh έΎϤϴΑΎҨήϣ έϮθ έΩ .Ζ γ Ϫόγ ϮΗϝ ΎΣ4/39ήϴϣϭn ήϣΪ λέΩ %
ήϫί ϊ ϗϭέΩϭΖ γ 5/2ϝ ΎϤΘΣ .Ζ γ ϗϭήϋ - ΒϠϗh Ύϫh έΎϤϴΑΖ ϠϋϪΑΩέϮϣ Ҩn ήϣίβ � ¥ Ϊ ϧίϝ ϮρέΩήϧϭή ϕ ϭήϋh Ύϫh έΎϤϴΑωϮϗϭ40ϥΩήϣh ήΑ � ϟΎγ40h ήΑϭΪ λέΩ
ϥΎϧί32ήϫί ϭΖ γ Ϊ λέΩ5έΩϭΖ γ ήϧϭή ϕ ϭήϋh Ύϫh έΎϤϴΑΖ ϠϋϪΑ ҨΎҨήϣ έΩn ήϣ.ΩϮη ϣΏϮδ ΤϣέϮθ ϦҨ έΩήϴϣϭn ήϣϞϣΎϋϦҨήΗϩΪ Ϥϋϊ ϗ ϭ
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h Ύϫh έΎϤϴΑˬβ ϨΟϭΩήϫέΩϭϦϴϨγ ϡΎϤΗέΩήϴϣϭn ήϣΖ ϠϋϦҨήΗϊ ҨΎη ϭϦϴϟϭ ΰϴϧϥ ήҨέΩΒϠϗ Ϟ ί ϭΖ γ ήϧϭή ϕ ϭήϋh Ύϫh έΎϤϴΑι ϮμΧϪΑ ϗϭήϋ700ΎΗ800Ϫˬϧίϭέn ήϣΩέϮϣ317 ϣ ϗϭήϋ ΒϠϗh Ύϫh έΎϤϴΑΖ ϠϋϪΑήϔϧ Ϫ Ϊ ϧήϴϣ166 ΒϠϗϪΘγ Ζ ϠϋϪΑϥ ΩέϮϣ
Ζ γ .
1., Descriptive epidemiology:= Describing distribution of cardiovascular disease by
means of certain characteristics such as : PERSON (i.e., age, gender, ethnicity) TIME and PLACE
2., Analytic epidemiology= Analyzing relationships between CVD and risk
factors (which elevate the probability of a disease at population level), risk model and multicausal developments
3., Experimental epidemiology/Interventions= Strategies of cardiovascular prevention (primordial,
primary, secondary, tertiary; individual and community levels)
PARTS OF CARDIOVASCULAR EPIDEMIOLOGY
In the world: CVD deaths account for one third of all deaths (25-50% depending on the level of economic development) among which 50%: coronary deaths
CVD made up 16.7 million of global deaths in 2002, among which 7 million due to coronary heart disease, 6 million due to stroke
Distribution of types of CVD in global deaths :Global cardiovascular deaths in 2002: 16.7 millionamong which: coronary heart disease 7.2 million >
stroke 6.0 million > 0.9 million hypertensive heart disease > 0.4 million inflammatory heart disease > 0.3 million rheumatic heart disease > 1.9 million other CVD
DESCRIPTIVE EPIDEMIOLOGY I. DISTRIBUTION PATTERNS IN THE
WORLD
Question: What is the relative amount of CVD in death rates in different age groups?
- Early lesions of blood vessel, atherosclerotic plaques: around 20 years - adult lifestyle patterns usually start in childhood and youth (smoking, dietary habits, sporting behavior, etc.)
- Increase in CVD morbidity and mortality: in age-group of 30-44 years
DESCRIPTIVE EPIDEMIOLOGY II. AGE
PROPORTION OF MORTALITY IN DIFFERENT AGE-GROUPS (MEN)
PROPORTION OF MORTALITY IN DIFFERENT AGE-GROUPS (WOMEN)
Question: What is the relative amount of CVD in death rates in women and men?
- Widespread idea: CVD is often thought to be a disease of middle-aged men.
- Cardiovascular mortality (fatal cases) are more common among men. However, CVD affect nearly as many women as men, albeit at an older age
- Women: special case (WHO, 2004) a., Higher risk in women than men (smoking, high
triglyceride levels) b., Higher prevalence of certain risk factors in women
(diabetes mellitus, depression) c., Gender-specific risk factors (risks for women only)
(oral contraceptives, polycystic ovary syndrome)
DESCRIPTIVE EPIDEMIOLOGY III. SEX
Question: What is the relative amount of CVD in death rates in different ethnic groups?
- In the US: increased cardiovascular disease deaths in African-American and South-Asian populations in comparison with Whites
- Increased stroke risk in African-American, some Hispanic American, Chinese, and Japanese populations
- Migration: Ni-Hon-San Study: Japanese living in Japan had the lowest rates of CHD and cholesterol levels, those living in Hawaii had intermediate rates for both, those living in San Francisco had the highest rates for both
DESCRIPTIVE EPIDEMIOLOGY IV. ETHNICITY
Developed countries: decreasing tendencies (e.g, USA: 30% between 1988-98, Sweden: 42%)
- improvement of lifestyle factors, for example, a decrease of smoking and a higher level of health consciousness in many developed countries
- better diagnostic and therapeutic procedures (e.g., bypass surgeries, hypertension screening, pharmacological treatment of hypertension and hypercholesterinaemia, access to health care)
Developing countries: increasing tendencies- increasing longevity, urbanization, and western
type lifestyle
DESCRIPTIVE EPIDEMIOLOGY VI. WORLD TRENDS
ANALYTIC EPIDEMIOLOGY II. CLASSIFICATION OF RISK FACTORS
Estimated 10-Year CHD Risk in 55-Year-Old Adults According to Levels of Various Risk Factors Framingham Heart Study
A B C DBlood Pressure (mm Hg) 120/80 140/90 140/90 140/90Total Cholesterol (mg/dL) 200 240 240 240HDL Cholesterol (mg/dL) 50 50 40 40Diabetes No No Yes YesCigarettes No No No Yes
5
13
25
58
20
27
37
05
10152025303540
A B C D
Estim
ated
10-
Year
Rat
e (%
)
MenWomen
2.6 4 5.48.4
1.1 2
19.122.4
14.8
27
6.33.5
0
5
10
15
20
25
30
A B C D E F
Est
imat
ed 1
0-Y
ear R
ate
(%)
Men Women
Estimated 10-Year Stroke Risk in 55-Year-Old Adults According to Levels of Various Risk Factors Framingham Heart Study
A B C D E FSystolic BP* 95-105 130-148 130-148 130-148 130-148 130-148Diabetes No No Yes Yes Yes YesCigarettes No No No Yes Yes YesPrior Atrial Fib. No No No No Yes YesPrior CVD No No No No No Yes
Source: Stroke 1991;22:312-318. *BP in millimeters of mercury (mmHg)
2.64 5.4
8.4
1.1 2
19.1
22.4
14.8
27
6.33.5
0
5
10
15
20
25
30
A B C D E F
Est
imat
ed 1
0-Y
ear R
ate
(%)
Men Women
A B C D E FSystolic BP* 95-105 130-148 130-148 130-148 130-148 130-148Diabetes No No Yes Yes Yes YesCigarettes No No No Yes Yes YesPrior Atrial Fib. No No No No Yes YesPrior CVD No No No No No Yes
Estimated 10-year stroke risk in 55-year-old adults according to levels of various risk factors (FHS). Source: Wolf et al., Stroke.1991;22:312-318.
*BP in millimeters of mercury (mmHg)
Offspring CVD Risk by Parental CVD Status: Framingham Study
0
0.5
1
1.5
2
2.5
MEN WOMEN
NONEMATERNALPATERNAL
Risk Ratio
1.0
1.7
2.2
1.0
1.7 1.7
Adjusted for: age, total/HDL Chol. ratio, SBP, smoking, diabetes, BMI
Parental CVD <55 men, <65 Women
Serum Cholesterol
Age: 35-64* Age: 65-94
MenWome
n Men+ Women*84-204
8 422 11
205-23413 5
24 15
235-26414 4
26 17
265-29415 7
23 17
295-1124 26 10
38 32
Risk of Coronary Heart Diseaseby Serum Cholesterol
30-Year Follow-up, The Framingham Study
*Trends Significant at P.001. +P.07.
Age-Adjusted Annual Rate per 1000
Q = serum cholesterol quintile. Kannel WB et al. Am Heart J. 1986;112:825-836.
Multiple Risk Factor Intervention Trial (MRFIT) N=325,346
Correlation Between Serum Cholesterol and CVD Mortality
6-Ye
ar C
VD D
eath
Rat
e Pe
r 100
0
0
5
10
15
20
25
30
Q1
(<182)Q2
(182-202)Q3
(203-220)Q4
(221-244)Q5
(>244)
35-39 years
40-44 years
45-49 years
50-54 years
55-57 years
Serum Cholesterol Quintile (mg/dL)
Untreated Patients
Lifetime Risk of CHD Increases with Serum Cholesterol
0
10
20
30
40
50
60
Perc
ent
Men Women
<200 mg200-239 mg>240 mg
Framingham Study: Subjects age 40 yearsDM Lloyd-Jones et al Arch Intern Med 2003; 1966-1972
34
44
57
19
29
33
Cholesterol
___________________________________________________________________________
_______________________________________________________________________________
Age-adjusted prevalence of Adults age 20 and older with LDL cholesterol of 130 mg/dL or higher, by race/ethnicity and sex (NHANES: 2003-2004). Source: NCHS and NHLBI. NH – non-Hispanic.
32.0 32.0 32.0
39.0
32.0 34.030.0 31.0
05
1015202530354045
Total Population NH Whites NH Blacks MexicanAmericans
Perc
ent o
f Pop
ulat
ion
Men Women
Age-adjusted prevalence of Adults age 20 and older with HDL cholesterol <40 mg/dL, by race/ethnicity and sex (NHANES: 2003-2004). Source: NCHS and NHLBI. NH – non-Hispanic.
25
16
9 97
13
26 28
05
1015202530
Total NH Whites NH Blacks MexicanAmericans
Perc
ent o
f Pop
ulat
ion
Men Women
Trends in mean total serum cholesterol among adults age 20 and older, by race/ethnicity, sex and survey (NHANES : 1988-94, 1999-02 and 2003-04). Source: NCHS and NHLBI. NH – non-Hispanic.
206
204205
204
199
202202
197
201
192
194196
198
200
202204
206
208
NH White NH Black Mexican American
Mea
n Se
rum
Tot
al C
hole
ster
ol
1988-94 1999-02 2003-04
Trends in mean total blood cholesterol among adolescents ages 12-17 by race, sex, and survey (NHES: 1966-70; NHANES: 1971-74 and 1988-94). Source: NCHS and NHLBI.
163
171 170
165
174
155
163161
172
166163
166 168164
156
161
145
150
155
160
165
170
175
180
White Males Black Males White Females Black Females
Mea
n To
tal B
lood
Cho
lest
erol
1976-80 1988-94 1999-02 2003-04
Prevalence of high blood pressure in Adults by age and sex (NHANES: 1999-2004). Source: NCHS and NHLBI.
11.2
37.4
55.4
73.9
23.2
37.549.1
63.669.5
6.4
83.8
18.3
0.010.020.030.040.050.060.070.080.090.0
20-34 35-44 45-54 55-64 65-74 75+
Perc
ent o
f Pop
ulat
ion
Men Women
CHD Risk by Cigarette Smoking. Filter Vs. Non-filter. Framingham Study. Men <55 Yrs.
0
50
100
150
200
250
Total CHD MyocardialInfarction
Non-SmokerReg. Cig. SmokerFilter Cig. Smoker
14-yr. Rate/1000
119
206 210
59
112210
3
2.4
1.8
1.2
0.6
0
(1971) (1989)
Q1 Q2 Q3 Q4 Q5 OverallThin Obese
Risk Factor Sum and Obesity(1971-74) and (1989-93)
Ris
k Fa
ctor
Sum
Risk variables include bottom quintile for HDL-C and top quintiles for cholesterol, SBP, triglycerides and glucose
Framingham Study
Risk factors accumulate with weight gain
Trends in prevalence of overweight among U.S. children and adolescents by age and survey (NHANES, 1971-74, 1976-80, 1988-94 and 2001-2004). Source: Health, United States, 2006, unpublished data. NCHS.
4.3 3.6
6.6 6.4
11.6 11
18.7
16.3
02468
101214161820
6-11 12-19
Perc
ent o
f Pop
ulat
ion
1971-74 1976-80 1988-94 2001-2004
- Systolic blood pressure >140 Hgmm and/or a diastolic blood pressure > 90 Hgmm
- Free of clinical symptoms for many years (screening)
- In most countries, up to 30 percent of adults suffering, increasing with age in civilized countries
- Positive family history- Dietary habits (a high intake of salt, processed food,
low levels of water hardness, high thyramine content of food, alcohol use)
- Modern lifestyle (increased sympathetic activity, psychosocial stress, leading position in job)
ANALYTIC EPIDEMIOLOGY II. CLASSIFICATION OF RISK FACTORS
Development: Rheumatic fever usually follows an untreated beta-haemolytic streptococcal throat infection in children
As a consequence, the heart valves are permanently damaged which may progress to heart failure
Today mostly affects children in developing countries, linked to poverty, inadequacy of health care access
Occurrence: 12 million people currently affected by rheumatic fever and RHD, two-thirds are children (5-15 years), for example: approx. 1 000 000 in Sub-Saharan Africa, 700 000 in South-Central Asia, 176 000 in China, 150 000 in North Africa, 40 000 in Eastern Europe (!)
ANALYTIC EPIDEMIOLOGY IV. RHEUMATIC FEVER AND RHEUMATIC HEART
DISEASE
- Se cholesterol: structure and functioning of blood vessels, atherosclerotic plaques
- Altering functions of cholesterol fractions (LDL: risk, HDL: protection)
- Estrogen: tends to raise HDL-cholesterol and lower LDL-cholesterol, protection for women in reproductive age
- Partially genetic determination of metabolism, partially dependent of nutrition (egg, meats, dairy products)
ANALYTIC EPIDEMIOLOGY V. ABNORMAL BLOOD LIPIDS
- The link between smoking and CVD (mainly CHD) was identified in 1940
- Passive smoking: additional risk- Women smokers: are at higher risk of CHD and CVD
than male smokers - Several mechanisms: damages the endothelium
lining, increases atherosclerotic plaques, raises LDL and lowers HDL, promotes artery spasms, raises oxigen demand of the heart muscle
- Nicotine accelerates the heart rate (HR), and raises blood pressure
ANALYTIC EPIDEMIOLOGY VI. TOBACCO USE
- Regular physical activity: protective factor- Intensity and duration (150 minutes/week
intermediate or 60 minutes/week heavy)- Modernization, urbanization, mechanized transport:
sedentary lifestyle (60% of global population)- Raises CVD risk and also the development of other
risk factors (glucose metabolism, diabetes mellitus, blood coagulation, obesity, high blood pressure, worsening lipid profile)
- Physical activity: helps reduce stress, anxiety and depression
ANALYTIC EPIDEMIOLOGY VII. PHYSICAL INACTIVITY
- Body Mass Index: > 25: overweight, > 30: obesity- A modern ”epidemic”: More than 60% of adults in
the US are overweight or obese, in China: 70 million overweight people
- Elevates the risk of both CVD and diabetes mellitus- Diabetes mellitus: damages both peripheral and
coronary blood vessels-Unhealthy diet: low fruit and vegetable, fiber
content, and high saturated fat intake, refined sugar
ANALYTIC EPIDEMIOLOGY VIII. OBESITY, DIABETES MELLITUS, UNHEALTHY
DIET
- Psychological factors (Type A behavior, hostility)- Depression and CVD: bidirectional linka., depression may increase the risk of CVD and
worsen recovery process b., CVD may induce depression - Low socioeconomic status (SES): a., in developed countries: less educated and lower
SES groups (accumulation of risk factors)b., in developing countries: more educated and
higher SES groups (western lifestyle)
ANALYTIC EPIDEMIOLOGY IX. PSYCHOLOGICAL AND SOCIAL
FACTORS
CMPN = communicable, maternal, perinatal , and nutr it ional diseases
CVD = cardiovascular disease
INJ = injury ONC = other
noncommunicable diseases.
(From Mathers CD, Lopez A , Stein D, et a l : Deaths and disease burden by cause: Global burden of disease est imates for 2001 by World Bank Country Groups, 2005. Disease Control Pr ior i t ies Working Paper 18 [http:/ /www.dcp2.org/file/33/wp18.pdf] . )
FIGURE 1-1 CHANGING PATTERN OF MORTALITY, 1990 TO 2001.