winslow homer: “white mountains”. epidemiology of cardiovascular disease brubaker, et. al....
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Winslow Homer: “White Mountains”
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Epidemiology of Epidemiology of Cardiovascular Cardiovascular
DiseaseDisease
Brubaker, et. al.
Chapter 1:1-22
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Definitions:Definitions: Epidemiology: Finding
demographic associationsPrevalenceCorrelationsRisk Factors and Prediction
Etiology: Cause / EffectMechanisms: How does this Cause cardiovascular disease?
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You Define: You Define:
Prevention:Intervention:Rehabilitation:
Where does the “Exercise Physiologist” most impact CAD?
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Cardiovascular DiseasesCardiovascular Diseases
Coronary Artery DiseaseAccounts for nearly 50% of all CVD
Arterial HypertensionLeft Ventricular Dysfunction
(Congestive Heart Failure)Valvular DiseaseCardiac Dysrhythmias
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““A Life Every 29 A Life Every 29 Seconds”Seconds”
The American Heart Association
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First the Good News:First the Good News:
Since 1988, deaths from CVD has declined about 20%!
BUT…BUT…
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Cardiovascular DiseaseCardiovascular DiseaseMortality rates increase - 1900sToday >1 million die each year!!Cost? Nearly $300 Billion / year!!!!The number of “Procedures” to
treat CAD has increased ~400% since 1979
Why did this disease become more prevalent after 1900?
How are risk factors identified?
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How Do We Do in How Do We Do in Nebraska?Nebraska?
From: NHLBI –http://hp2010.nhlbihin.net/cvd_frameset.htm
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Compared to Texas:Compared to Texas:
Houston voted the “Fattest City in USA”
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Or Colorado:Or Colorado:
Colorado Springs voted the “Most FitCity in the USA”
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Conclusion:Conclusion: As we know more and the public
is more aware of the various genetic and lifestyle risk factors, Primary Prevention Programs may gain impact strength.
We have better therapies.More people are SURVIVING
CAD, and will benefit from Secondary Prevention Programs.
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You Define:You Define:Primary Prevention:Secondary Prevention:
Risk Factor IDRisk Factor Reduction
What is the Primary Role of PREVENTION in Cardiac Rehab?
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RISKRISKAbsolute vs. Relative Absolute vs. Relative An individual’s
chance (risk, probability) of developing CAD in the next 5-10 years…
But what does it MEAN?
Comparing that individual’s risk to others like him or her…
RR = iAR/pAR
iAR = individual’s AR
pAR = population AR
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Case Study #1:Case Study #1: Fred is 38, with
hypertension and a poor blood lipid profile:
His Absolute Risk is 7%
The average risk for males 35-39 is 5%
7% / 5% = 1.4 times the risk of developing CAD…
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All About Risk Factors:All About Risk Factors:Traditional: Well documented,
understood risk factors -The big “9”Emerging: Evidence is mounting
linking these factors to CADMarkers: Other characteristics
linked to CAD – perhaps indicating a genetic “cluster” of characteristics
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You may ask…You may ask…Where do they get the
population data to determine absolute and relative risk?
Framingham Risk Score: Page 21
That brings us to “Epidemiological Studies”
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Study Designs: Study Designs: Epidemiological: Large
“cohorts” for longitudinal studies:Looking for “Relationships”
Intervention: Modifying suspected risk factors, and measuring CAD outcomes
Randomized Clinical Trials: Not feasible nor ethical
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Framingham Heart StudyFramingham Heart Study City of Framingham, MA (pop 50,000) Massive health screenings every 2
years 30+ year study (1948- ) Looked at various health factors
related to disease and mortality Some factors seemed to be
significantly associated with (correlated with) CVD
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Traditional Risk FactorsNon-Mod vs. Modifiable Increasing Age Male Gender Family History
Tobacco Use High Cholesterol Hypertension Physical Inactivity Obesity Diabetes
The “Big 9”: 6 Targets of Prevention
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After Framingham: After Framingham: Read through your references at the
end of this chapter…I.e. NHANES III (Nat’l Health and Nutrition Examination Survey)
Framingham is the “Grand Daddy” of CAD Epidemiological Studies.
This is usually “Step One” in determining what is causing a “rash of illnesses” such as seen with CVD after 1900
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Intervention: Zeroing in Intervention: Zeroing in on Cause-Effecton Cause-EffectOnce a factor (I.e. Smoking) is
linked to the risk of developing CAD,
Study the effect of intervening with the risk factor (I.e. quit smoking) on CAD risk…
MRFIT: Multiple Risk Factor Intervention Trial
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A Closer Look at the A Closer Look at the Traditional Risk Factors: Traditional Risk Factors:
Know the “Big 9” Know the 6
Modifiable Factors
Know the acceptable levels for PRIMARY PREVENTION
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Assignment: Assignment: Read: Foster, Procari. (2001).
The risks of exercise training. J.Cardiopulm.Rehab. 21(6):347-351.
Be ready to discuss: What are the benefits and challenges to increasing physical activity as Secondary Prevention?
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Hearts in the News:Hearts in the News:
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““President Bush Faints President Bush Faints After Choking on Pretzel”After Choking on Pretzel”His resting Heart Rate made
the news last year…Can you think what might have
influenced his brief fainting spell?
Think “baroreceptors”…Vasovagal Syncope
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Tobacco:Tobacco:Just DON’T!Acute cardiovascular affects of nicotine
include hypertension, increased O2 demand by the heart, and decreased O2 delivery, risk of arrhythmias, and coronary artery spasm, and platelet aggregation
Every smoke puts a person a risk, but especially someone with progressing CAD!
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RISK FACTOR: Chronic RISK FACTOR: Chronic Tobacco UseTobacco UseDecreases HDL cholesterol/LDL
oxidation Damages arterial endotheliumBegins atherosclerosis
Increases chronic blood pressure by increased Smooth Muscle proliferation
Increases Fibrinogen, RBC and blood viscosity.
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Hyperlipidemia: High Fat Hyperlipidemia: High Fat in the Blood…in the Blood…Cholesterol “Types”:
Total: All types combinedHDL: High Density LipoproteinsLDL: Low Density Lipoproteins
Tell me what you know?
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HDL: HDL: The “Good Guys” Inversely related to CAD:
As HDL goes UP – CAD goes DOWN“Reverse-Cholesterol Transport”
HDL’s may prevent cholesterol from becoming atherogenic and may even remove cholesterol from atherosclerotic arteries!
HDL > 60 mg/dl reduces CAD riskHDL < 40 mg/dl increases risk
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LDL: LDL: The “Bad Guys”LDL carries cholesterol to the
peripheral arteries.It is Oxidized by endothelial cell
products…and acts as an “offending presence” injuring vessel walls:
LDL > 130 mg/dl increases CAD risk
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Triglycerides:Triglycerides:Triglycerides are associated with
increased risk for CADBUT: blood TG’s vary greatly in
“feast”/famine and between individual responses to “feasts”
May be more of a Marker associated with obesity, physical inactivity, glucose intolerance etc.
TG > 150 mg/dl increases CAD risk
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HypertensionHypertension
Damages vessel walls Increases afterload on the heart (=
more work)Leading cause of stroke & heart
failureAffects 40% of the U.S. !BP > 140 systolic and/or 90
diastolic increases CAD risk
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Physical Inactivity Physical Inactivity
Physical Activity and/or Cardiorespiratory Fitness
Many intervention studiesHow Much? How Intense?
Assignment: You Tell Me!
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Physical InactivityPhysical InactivitySee current Surgeon General’s
Report60% of Americans get no exercise!Contributes to CVD, obesity,
musculoskeletal disorders, GI disturbances, cancer, stress, HTN, high blood lipids, glucose intolerance
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Glucose IntoleranceGlucose Intolerance May be partial intolerance, or full
(diabetes) High blood glucose will oxidize, destroying
cell walls Atherosclerosis is greatly accelerated Risk of clotting is increased Increases the risk of CAD >3 times in
Women! Often associated with other risk factors:
Obesity, hyperlipidemia etc.
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RISK FACTOR: ObesityRISK FACTOR: Obesity
Location of fat distribution matters 25% attributed to genetics Most due to environment Increases HTN, glucose intolerance,
insulin resistance, triglycerides, decreases HDL,
BMI > 25 increases CAD risk in both men and women (more in men)
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Percent of U.S. Population at Risk
0
10
20
30
40
50
60
BP TC SMOKE INACT
%
Risk Ratio2.1 2.4 2.5 1.9
from Casperson, C.J. Phys. Sports Med. 15:43-44, 1987.
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Domains of CVD Domains of CVD Prevention: PrimaryPrevention: Primary
Strategies for apparently healthyGoal is to prevent onset of diseaseLifestyle changesFocus is on youth, young adults
and CAD-free adults
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Secondary PreventionSecondary PreventionDesigned to improve outcome of
those with diseaseRisk profiles are very different after
CAD has “reared it’s ugly head”Goal is to reduce the risk of
SUBSEQUENT CAD eventsStrategies in primary prevention
also implemented – but more aggressively
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Assignment: Assignment: Physical Activity Guidelines for
Primary Prevention – Cite your source.
Evaluate your AR and RR!Other emerging or controversial
risk factors:Groups of 3-4: Mini-ReportsDue Tuesday
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Mini-Reports: 20 pts Mini-Reports: 20 pts Pages 17-19AHA/NHLBI Website helps:NHLBI: Web SiteAmerican Heart Association1-3 minutes:
What is it?Why do we think it may affect CAD risk?