Mississippi State Plan for Mississippi State Plan for Heart Disease and Stroke Heart Disease and Stroke

Prevention and ControlPrevention and Control

J. Clay Hays, Jr., M.D.J. Clay Hays, Jr., M.D.

Purpose of the PlanPurpose of the Plan

Provide framework to reduce morbidity Provide framework to reduce morbidity and mortality associated with CVDand mortality associated with CVD

Provide educationProvide educationCreate healthy environmentCreate healthy environmentProvide quality health servicesProvide quality health servicesFocuses on disparities between groupsFocuses on disparities between groups

We’re Number 1!We’re Number 1!

We lead the nation in heart We lead the nation in heart disease and strokedisease and stroke

Who developed the Plan?Who developed the Plan?

PartnershipPartnership

Miss. State Dept of HealthMiss. State Dept of HealthMiss. Chronic Illness Coalition- CVD Miss. Chronic Illness Coalition- CVD

Advisory CommitteeAdvisory CommitteeMiss. Task Force on Heart Disease and Miss. Task Force on Heart Disease and

Stroke PreventionStroke Prevention

Who do we plan to target?Who do we plan to target?

EveryoneEveryoneGenderGenderRaceRaceSocioeconomic statusSocioeconomic statusOther cultural factorsOther cultural factors

How do we expect to accomplish How do we expect to accomplish our Goals?our Goals?

Policy and environmental interventions Policy and environmental interventions focusing on populations instead of focusing on populations instead of individualsindividuals

Partnership developmentPartnership developmentAddress specific community needsAddress specific community needs

Develop a DatabaseDevelop a Database

Why did We decide to do Why did We decide to do this?this?

Mississippi StatsMississippi Stats

CVD is leading cause of death- 41% in CVD is leading cause of death- 41% in 20012001

Our CVD mortality rate is the highest in Our CVD mortality rate is the highest in the countrythe country

One in five occurs in people <65 oldOne in five occurs in people <65 oldPrevalence- 4.3% heart disease and 2.4% Prevalence- 4.3% heart disease and 2.4%

strokestroke160,000 Mississippians reported CVD160,000 Mississippians reported CVD

More factsMore facts

Mortality worse in men than in womenMortality worse in men than in womenAfrican americans> whitesAfrican americans> whitesClaiborne county has the highest (675 per Claiborne county has the highest (675 per

100,000)100,000)Three fourths of Miss. have one risk factorThree fourths of Miss. have one risk factorCost 3.7 billionCost 3.7 billion

Coronary Artery Disease (CAD):Coronary Artery Disease (CAD):The Diagnosis Often Comes Too The Diagnosis Often Comes Too

LateLate

(Adapted from Levy et al.)(Adapted from Levy et al.)

Levy D et al in Levy D et al in Textbook of Cardiovascular MedicineTextbook of Cardiovascular Medicine, 1998., 1998.

American Heart Association, 2000 Heart and Stroke Statistical Update, 1999; Braunwald E, N Engl J Med, 1997;Kannel WB in Atherosclerosis and Coronary Artery Disease, 1996.

Vascular Disease: Scope of the Vascular Disease: Scope of the ProblemProblem

Vascular Disease: Scope of the Vascular Disease: Scope of the ProblemProblem

Vascular disease—and CAD in particular—Vascular disease—and CAD in particular—is the leading cause of death in the US and is the leading cause of death in the US and other Western nationsother Western nations

By 2020, cardiovascular disease will become By 2020, cardiovascular disease will become the most common cause of death worldwidethe most common cause of death worldwide

Due to the high initial mortality of vascular Due to the high initial mortality of vascular disease, the target of clinical practice must disease, the target of clinical practice must be aggressive risk factor managementbe aggressive risk factor management

Atherosclerosis: A Systemic Atherosclerosis: A Systemic DiseaseDisease

Atherosclerosis: A Systemic Atherosclerosis: A Systemic DiseaseDisease

Aronow WS et al, Am J Cardiol, 1994.

From a prospective analysis of 1886 patients aged From a prospective analysis of 1886 patients aged 62 years, 810 patients were diagnosed with CAD as defined by a documented clinical history of MI, ECG 62 years, 810 patients were diagnosed with CAD as defined by a documented clinical history of MI, ECG evidence of Q-wave MI, or typical angina without previous MI. (Adapted from Aronow et al.)evidence of Q-wave MI, or typical angina without previous MI. (Adapted from Aronow et al.)

Major Risk Factors for CADMajor Risk Factors for CAD

Grundy SM et al, Circulation, 1998; Grundy SM, Circulation, 1999.

Most Myocardial Infarctions Are Most Myocardial Infarctions Are CausedCaused

by Low-Grade Stenosesby Low-Grade Stenoses

Pooled data from 4 studies: Ambrose et al, 1988; Little et al, 1988; Nobuyoshi et al, 1991; and Giroud et al, 1992.Pooled data from 4 studies: Ambrose et al, 1988; Little et al, 1988; Nobuyoshi et al, 1991; and Giroud et al, 1992.(Adapted from Falk et al.)(Adapted from Falk et al.)Falk E et al, Circulation, 1995.

(Adapted from Glagov et al.)(Adapted from Glagov et al.)

Coronary RemodelingCoronary RemodelingCoronary RemodelingCoronary Remodeling

NormalNormalvesselvessel

MinimalMinimalCADCAD

ProgressionProgression

Compensatory expansionCompensatory expansionmaintains constant lumenmaintains constant lumen

Expansion Expansion overcome:overcome:

lumen narrowslumen narrows

SevereSevereCADCAD

ModerateModerateCADCAD

Glagov et al, Glagov et al, N Engl J MedN Engl J Med, 1987., 1987.

Atheroma Morphology by UltrasoundAtheroma Morphology by Ultrasound

““Soft” Lipid-Laden PlaqueSoft” Lipid-Laden Plaque““Soft” Lipid-Laden PlaqueSoft” Lipid-Laden Plaque ““Hard” Fibrous PlaqueHard” Fibrous Plaque““Hard” Fibrous PlaqueHard” Fibrous Plaque

Thin Cap With Lipid CoreThin Cap With Lipid CoreThin Cap With Lipid CoreThin Cap With Lipid Core Thick Stable Fibrotic CapThick Stable Fibrotic CapThick Stable Fibrotic CapThick Stable Fibrotic Cap

Same Lumen Size: Different AtheromasSame Lumen Size: Different Atheromas

Atherosclerosis Begins in Atherosclerosis Begins in ChildhoodChildhood

(Adapted from Berenson et al.)(Adapted from Berenson et al.)Berenson GS et al, N Engl J Med, 1998.

Tuzcu EM et al, in press.

One in Six Teenagers Has One in Six Teenagers Has AtheromasAtheromas

(Adapted from Tuzcu et al.)(Adapted from Tuzcu et al.)(Adapted from Tuzcu et al.)(Adapted from Tuzcu et al.)

CAD: Silent Disease Necessitates CAD: Silent Disease Necessitates Aggressive Risk Factor ManagementAggressive Risk Factor Management

IVUS corroborates necroscopy studies, IVUS corroborates necroscopy studies, proving that atherosclerosis begins in youthproving that atherosclerosis begins in youth

CAD progresses silently; the initial CAD progresses silently; the initial presentation is usually MI or sudden deathpresentation is usually MI or sudden death

Most atheromas are extraluminal, rendering Most atheromas are extraluminal, rendering them angiographically silentthem angiographically silent

The only reasonable approach is early and The only reasonable approach is early and aggressive risk factor managementaggressive risk factor management

Berenson GS et al, N Engl J Med, 1998; Tuzcu EM et al, in press; Levy D et al in Textbook of Cardiovascular Medicine, 1998; Yamashita T et al, Progress in Cardiovascular Diseases, 1999; Topol EJ et al, Circulation, 1995. Kannel WB in Atherosclerosis and Coronary Artery Disease, 1996.

The Correlation Between The Correlation Between Atherosclerosis and Risk Factors Atherosclerosis and Risk Factors

Begins Early Begins Early

(Adapted from Berenson et al.)(Adapted from Berenson et al.)

Berenson GS et al, N Engl J Med, 1998.

Small Increases in Cholesterol Small Increases in Cholesterol Lead to Dramatic Increases in Lead to Dramatic Increases in

CAD DeathCAD Death

(Adapted from Neaton et al.)(Adapted from Neaton et al.)

Neaton JD et al, Arch Intern Med, 1992.

CAD: Not Just a Lipid DiseaseCAD: Not Just a Lipid Disease Half of all MIs occur in normolipidemic patientsHalf of all MIs occur in normolipidemic patients

SmokingSmokingAccounts for 200,000 cardiovascular deaths annuallyAccounts for 200,000 cardiovascular deaths annually

DiabetesDiabetesAffects 16 million Americans—and is growingAffects 16 million Americans—and is growing

HypertensionHypertensionConfers as much risk for MI as smoking or dyslipidemiaConfers as much risk for MI as smoking or dyslipidemia Systolic hypertensionSystolic hypertension is an even greater indicator of CAD risk is an even greater indicator of CAD risk

than diastolic hypertensionthan diastolic hypertension

Braunwald E, N Engl J Med, 1997; Grundy SM et al, Circulation, 1998; The Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure and the National High Blood Pressure Education Program Coordinating Committee, Arch Intern Med, 1997.

Systolic BP Confers Incremental RiskSystolic BP Confers Incremental RiskEven Within “Normal” LevelsEven Within “Normal” Levels

(Adapted from Neaton et al.)(Adapted from Neaton et al.)

Neaton JD et al, Arch Intern Med, 1992.

Diabetes: Half of All PatientsDiabetes: Half of All PatientsAre Unaware of Their ConditionAre Unaware of Their Condition

CAD is the leading cause of hospitalization and death among patients CAD is the leading cause of hospitalization and death among patients with type 2 diabetes (NIDDM)with type 2 diabetes (NIDDM)

Patients with both type 1 and type 2 diabetes are at a high short-term Patients with both type 1 and type 2 diabetes are at a high short-term risk of CAD-related end pointsrisk of CAD-related end points

Insulin resistance increases risk and may exist for 25 years or more Insulin resistance increases risk and may exist for 25 years or more before diabetes is diagnosedbefore diabetes is diagnosed

Patients with diabetes tend to cluster other risk factors (such as Patients with diabetes tend to cluster other risk factors (such as hypertension and dyslipidemia) while diabetes confers risk unto itselfhypertension and dyslipidemia) while diabetes confers risk unto itself

Aronson D et al in Atherosclerosis and Coronary Artery Disease, 1996; Grundy SM et al, J Am Coll Cardiol, 1999.

UK Prospective Diabetes Study Group, BMJ, 1998.

*UK Prospective Diabetes Study Group.*UK Prospective Diabetes Study Group. *UK Prospective Diabetes Study Group.*UK Prospective Diabetes Study Group.

UKPDS*: The Case for AggressiveUKPDS*: The Case for AggressiveBlood Pressure ControlBlood Pressure Control

UKPDS*: The Case for AggressiveUKPDS*: The Case for AggressiveBlood Pressure ControlBlood Pressure Control

Mean final BP: More-aggressive control, 144/82 mm HgMean final BP: More-aggressive control, 144/82 mm Hg Less-aggressiveLess-aggressive control, 154/87 mm Hg control, 154/87 mm Hg

Mean final BP: More-aggressive control, 144/82 mm HgMean final BP: More-aggressive control, 144/82 mm Hg Less-aggressiveLess-aggressive control, 154/87 mm Hg control, 154/87 mm Hg

How do we plan to address How do we plan to address problems?problems?

Physical ActivityPhysical ActivityAddress Nutritional needsAddress Nutritional needsTobacco cessationTobacco cessation Identify Sociocultural Factors (Jackson Identify Sociocultural Factors (Jackson

Heart Study)Heart Study)

CAD Risk Factors: Minimal and CAD Risk Factors: Minimal and OptimalOptimal

Grundy SM, Circulation, 1999; American Heart Association Consensus Panel, Circulation, 1995; The Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure and the National High Blood Pressure Education Program Coordinating Committee, Arch Intern Med, 1997.

Multiple Risk Factors: Additive RiskMultiple Risk Factors: Additive Risk

Grundy SM et al, J Am Coll Cardiol, 1999; Data on file, Pfizer Inc., New York, NY.

Risk of developing CAD over 10 years according to specified BP levels and other risk factors. Calculations are based on a Framingham Risk of developing CAD over 10 years according to specified BP levels and other risk factors. Calculations are based on a Framingham Heart Study computer program, which includes variables for systolic BP, diastolic BP, TC, HDL-C, LVH by ECG, cigarette smoking, and Heart Study computer program, which includes variables for systolic BP, diastolic BP, TC, HDL-C, LVH by ECG, cigarette smoking, and glucose intolerance. The following remained constant unless otherwise indicated: male, age 45 years, TC 180 mg/dL, HDL 45, and glucose intolerance. The following remained constant unless otherwise indicated: male, age 45 years, TC 180 mg/dL, HDL 45, and nonsmoker. Elevated LDL-C estimated based on TC 250 mg/dL with triglycerides 200 mg/dL. (Data on file, Pfizer Inc.)nonsmoker. Elevated LDL-C estimated based on TC 250 mg/dL with triglycerides 200 mg/dL. (Data on file, Pfizer Inc.)

OBESITYOBESITY

Where do we Start?Where do we Start?

CommunitiesCommunitiesSchoolsSchoolsWorksitesWorksitesHealthcare centersHealthcare centers

ConclusionsConclusions: Risk Factor : Risk Factor ManagementManagement

ConclusionsConclusions: Risk Factor : Risk Factor ManagementManagement

AtherosclerosisAtherosclerosis begins in childhood and is strongly begins in childhood and is strongly associated with major CAD risk factors from the youngest associated with major CAD risk factors from the youngest agesages

Hypertension (particularly systolic), diabetes, and smoking—Hypertension (particularly systolic), diabetes, and smoking—in addition to dyslipidemia—confer comparable risks in addition to dyslipidemia—confer comparable risks

The effect of these risk factors is The effect of these risk factors is continuouscontinuous, extending even , extending even into the “normal” rangeinto the “normal” range

Therefore, aggressive risk factor modification is the most Therefore, aggressive risk factor modification is the most effective strategy for reducing the consequences of CADeffective strategy for reducing the consequences of CAD

AtherosclerosisAtherosclerosis begins in childhood and is strongly begins in childhood and is strongly associated with major CAD risk factors from the youngest associated with major CAD risk factors from the youngest agesages

Hypertension (particularly systolic), diabetes, and smoking—Hypertension (particularly systolic), diabetes, and smoking—in addition to dyslipidemia—confer comparable risks in addition to dyslipidemia—confer comparable risks

The effect of these risk factors is The effect of these risk factors is continuouscontinuous, extending even , extending even into the “normal” rangeinto the “normal” range

Therefore, aggressive risk factor modification is the most Therefore, aggressive risk factor modification is the most effective strategy for reducing the consequences of CADeffective strategy for reducing the consequences of CAD

Berenson GS et al, N Engl J Med, 1998; Braunwald E, N Engl J Med, 1997; Neaton JD et al, Arch Intern Med, 1992; Kannel WB inAtherosclerosis and Coronary Artery Disease, 1996.

“Awaiting overt signs and symptoms of coronary diseasebefore treatment is no longer justified.”

“In some respects, the occurrence of symptoms may be regarded more properly as a medical failure than as the initial indication for treatment.”

—William B. Kannel, MDDepartment of MedicineBoston University Medical Center

“Awaiting overt signs and symptoms of coronary diseasebefore treatment is no longer justified.”

“In some respects, the occurrence of symptoms may be regarded more properly as a medical failure than as the initial indication for treatment.”

—William B. Kannel, MDDepartment of MedicineBoston University Medical Center

Kannel WB in Atherosclerosis and Coronary Artery Disease, 1996.

Carotid Disease:Carotid Disease:A Reliable Predictor of Coronary RiskA Reliable Predictor of Coronary Risk Carotid atherosclerosis, even when very mild,Carotid atherosclerosis, even when very mild,

is associated with MI and sudden cardiac deathis associated with MI and sudden cardiac death

Ultrasound-derived carotid intimal-medial thickness Ultrasound-derived carotid intimal-medial thickness (IMT) has been shown to predict the risk of MI(IMT) has been shown to predict the risk of MI

The same risk factors predispose patients to The same risk factors predispose patients to atherosclerosis in atherosclerosis in bothboth the coronary and carotid the coronary and carotid arterial systemsarterial systems

Salonen R in Risk Factors for Ultrasonographically Assessed Common Carotid Atherosclerosis, 1991; O’Leary DH et al, N Engl J Med, 1999; Androulakis AE et al, Eur Heart J, 2000.