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