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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
Disclosures
• Conflicts of interest: none
• Off-label use of drugs or devices: none
Global Burden of Cardiovascular DiseaseGlobal 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
CardiovascularCardiovascular
16.7 million
HIVTB
Malaria
HIVTB
Malaria
5 million
Lopez. Lancet 2006; Reddy. NEJM 2004Lopez. Lancet 2006; Reddy. NEJM 2004
2002 statistics
International Comparison
170
183
212
289
413
557
714
1555
0 200 400 600 800 1000 1200 1400 1600
Japan
France
Canada
USA
Rural China
Poland
Hungary
Russia
CVD Death Rates/100,000 (Men ages 35-74)
Cardiovascular Disease in the Americas
Highest
Lowest
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
Modified Model of the Epidemiological Transition as it
Pertains to Cardiovascular Disease
Yusef et al. Circulation 2001;104:276-2753
Stage 1: Age of Pestilence and Famine
Life expectancy < 55 years
CVD deaths 5-10% of total deaths
< 5% of years of life lost (YLL)
Prominent CV diseases and risk factors
Rheumatic heart disease, infections, nutritional cardiomyopathies
Regional examples Sub-Saharan Africa, rural India, Haiti
Stage 1: Haiti
Life expectancy = 55 years
Causes of Death Haiti 2002Cause of Death Deaths YLL
HIV/AIDS 22% 20%
Lower respiratory infections 7% 9%
Cerebrovascular disease 6% 3%
Meningitis 5% 7%
Diarrheal diseases 5% 7%
Perinatal conditions 4% 7%
Tuberculosis 4% 4%
Hypertensive heart disease 3% 1%
Anemia 3% 4%
Diabetes mellitus 3% 1%
Stage 2: Age of Receding Pandemics
Life expectancy 55-65 years
CVD deaths 10-35% of total deaths
Prominent CV diseases and risk factors
Rheumatic heart disease, infections, nutritional cardiomyopathies, hypertensive heart disease, hemorrhagic strokes
Regional examples Southeast Asia, rural China, Central and South America, Bolivia
Stage 2: Bolivia
Life expectancy = 65 years
Causes of Death Bolivia 2002Cause of Death Deaths YLL
Lower respiratory infections 9% 12%
Perinatal conditions 8% 14%
Diarrheal diseases 6% 10%
Ischemic heart disease 5% 2%
Cerebrovascular disease 4% 2%
Tuberculosis 4% 4%
Cirrhosis of the liver 3% 2%
Nephritis and nephrosis 3% 2%
Cervix and uterine cancers* 2% 2%
Diabetes mellitus 2% 1%
Stage 3: Age of Degenerative and Man-Made Diseases
Life expectancy 65-75 years
CVD deaths 35-65% of total deaths
Prominent CV diseases and risk factors
All forms of stroke, ischemic heart disease at young ages, increasing obesity and diabetes
Regional examples Eastern Europe, China, urban India, Non-Hispanic Caribbean, Jamaica
Stage 3: Jamaica
Life expectancy = 72 years
Causes of Death Jamaica 2002Cause of Death Deaths YLL
Cerebrovascular disease 18% 11%
Diabetes mellitus 11% 8%
Ischemic heart disease 10% 6%
Hypertensive heart disease 6% 4%
Lower respiratory infections 4% 4%
HIV/AIDS 4% 9%
Stomach cancer 3% 2%
Nephritis and nephrosis 3% 3%
Perinatal conditions 2% 8%
Breast cancer 2% 3%
Yang. Lancet, 2008Yang. Lancet, 2008
0
20
40
60
80
100
1973 2005
Changing Distribution of the Causes ofDeath in Peoples Republic of China
Changing Distribution of the Causes ofDeath in Peoples Republic of China
Pro
po
rtio
n o
f d
eath
s (%
)P
rop
ort
ion
of
dea
ths
(%)
YearYear
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
Stage 4: Age of Delayed Degenerative Diseases
Life expectancy > 75 years
CVD deaths 50% 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
Causes of Death USA 2002Cause of Death Deaths YLL
Ischemic heart disease 21% 15%
Cerebrovascular disease 7% 4%
Trachea, bronchus, lung cancers 7% 7%
Chronic obstructive pulmonary disease 5% 4%
Alzheimer and other dementias 4% 1%
Diabetes mellitus 3% 3%
Colon and rectum cancers 3% 3%
Lower respiratory infections 3% 2%
Breast cancer 2% 2%
Road traffic accidents 2% 6%
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
Years1996-2004
Hospital discharges for cardiovascular diseases. Hospital discharges for cardiovascular diseases. (United States: 1970-2006). Note: Hospital discharges (United States: 1970-2006). Note: Hospital discharges include people discharged alive, dead and status include people discharged alive, dead and status unknown. unknown. Source: NCHS and NHLBI.Source: NCHS and NHLBI.
0
1
2
3
4
5
6
7
70 75 80 85 90 95 00 06
Years
Dis
ch
arg
es i
n M
illi
on
s
Estimated direct and indirect costs (in billions of dollars) Estimated direct and indirect costs (in billions of dollars) of major cardiovascular diseases and stroke of major cardiovascular diseases and stroke (United States: 2009). (United States: 2009). Source: NHLBI.Source: NHLBI.
165.4
68.9 73.4
37.2
0
40
80
120
160
200
Coronary HeartDisease
Stroke HypertensiveDisease
Heart Failure
Bil
lio
ns
of
Do
llar
s
Total Cost = 344.9 billion dollars
Transition Factors 1 → 2
Sanitation – water qualityImmunizationAntibiotics
Population growthOlder population
Increased mechanization of food productionMore processed food
Increased salt intake
HypertensionHypertensive heart diseaseHemorrhagic stroke
Transition Factors 2 → 3
Changing economyAffluenceMass media
Cigarette smokingReduced physical activityIncreased caloric intakeMore meat consumptionObesity
DiabetesHyperlipidemiaIschemic StrokeMI
Incubation Period for Chronic Disease
Transition Factors 3 → 4
More educated publicIncreased spending on medical careSecondary prevention practicesPrimary prevention practices
Improved survival from MIReduced MI, stroke at young ages
CHD Trends
McGovern et al, Circulation 2001;104:19-24
Reduction in CVD Death Rate in US
Pre-1985 due largely to lifestyle changes
• Smoking cessation59% 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]
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
Causes of Death Honduras versus USWhere is Honduras in the Epidemiologic Transition?
Source: Death and Daly estimates by cause, 2002http://www.who.int/entity/healthinfo/statistics/bodfbddeathdalyestimates.xls
Causes of Death Honduras 2002Cause of Death Deaths YLL
Ischemic heart disease 11% 4%
HIV/AIDS 9% 14%
Perinatal conditions 7% 13%
Cerebrovascular disease 5% 3%
Diabetes mellitus 4% 2%
Diarrheal diseases 4% 7%
Lower respiratory infections 4% 5%
Nephritis and nephrosis 4% 2%
Hypertensive heart disease 3% 1%
Protein-energy malnutrition 3% 5%
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%
Honduras versus US Statistics
• Total expenditure on health per capita– Honduras: $241 US: $6,714
• Gross national income per capita– Honduras: $3,240 US: $44,070
• Total expenditure on health as % of GDP– Honduras: 7.4% US: 15.3%
World Health Statistics 2008Financial data from 2006
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%
Risk Factors, Honduras
Risk Factors, Honduras
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
In US we treat coronary disease with devices
$26,000 USD $5,000 USD$93,000 USD
Some less expensive devices to treat coronary disease
$19.95 USD $8.09 USD $5.95 USD
Greetings from Rochester, MN(winter)
• Comments?
• Questions?