Hall A 1 Thomas Allison Global burden of CV disease 2

Greetings from Rochester, MN


Global Burden of Cardiovascular Disease
Lessons for Vietnam from Experience of USA and
Other Countries?
Dr. Thomas G. Allison
Cardiovascular Diseases and Internal Medicine
Mayo Clinic
Rochester, MN


CV Trends in USA



Is the US experience being repeated
internationally?
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 potential
life lost (YPLL)
Prominent CV diseases Rheumatic heart disease,
and risk factors
infections, nutritional
cardiomyopathies
Example

Sub-Saharan Africa


Congo
• Life expectancy m/f = 53/55 years
• HIV/AIDS is #1 cause of death
– 25% of deaths and 27% of YPLL

• Malaria is #2 cause of death
– 12% of deaths and 15% of YPLL

• Measles is #3 cause of death
– 7% of deaths and 10% of YPLL

• Ischemic heart disease is #6 cause of death
– 4% of deaths and 1% of YPLL

• Cerebrovascular disease is #8 cause of death
– 4% of deaths and 1% of YPLL

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

Example

Bangledesh


Bengladesh
• Life expectancy m/f = 63/63 years
• Ischemic heart disease is #1 cause of death
– 12% of deaths and 6% of YPLL

• Lower respiratory infections is #2 cause of death
– 11% of deaths and 13% of YPLL

• Perinatal conditions is #3 cause of death
– 8% of deaths and 13% of YPLL

• Tuberculosis is #4 cause of death
– 7% of deaths and 7% of YPLL

• Diarrhea #5 cause of death
– 6% of deaths and 9% of YPLL

• Cerebrovascular disease is #6 cause of death
– 5% of deaths and 2% of YPLL


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


Bulgaria
• Life expectancy m/f = 69/76 years
• Ischemic heart disease is #1 cause of death
– 25% of deaths and 21% of YPLL

• Cerebrovascular disease is #2 cause of death
– 20% of deaths and 16% of YPLL

• Hypertensive heart disease is #3 cause of death
– 4% of deaths, 4% of YPLL

• Trachea, bronchus, lung cancer is #4
– 4% of deaths, 3% of YPLL


Stage 4: Age of Delayed Degenerative
Diseases
Life expectancy

> 75 years

CVD deaths

50% of total deaths

Prominent CV
diseases and risk
factors
Regional
examples

Stroke and ischemic heart disease at
old age
Western Europe, North America,
Australia and New Zealand


USA
• Life expectancy m/f = 75/80 years
• Ischemic heart disease is #1 cause of death
– 21% of deaths and 15% of YPLL

• Cerebrovascular disease is #2 cause of death
7% of deaths and 4% of YPLL

• Trachea, bronchus, lung cancer is #3
– 7% of deaths, 7% of YPLL

• Alzheimer’s, other dementias is #5
– 4% of deaths, 1% of YPLL


Transition Factors 1 → 2

Sanitation – water quality
Immunization
Antibiotics

Increased salt intake

Hypertension
Hypertensive heart disease
Hemorrhagic stroke

Population growth
Older population

Increased mechanization
of food production
More processed food


Transition Factors 2 → 3
Changing economy
Affluence
Mass media

Obesity
Diabetes
Hyperlipidemia
Ischemic Stroke
MI

Cigarette smoking

Reduced physical
activity
Increased caloric intake
More meat consumption


Incubation Period for Chronic Disease


Transition Factors 3 → 4
More educated public
Increased spending on medical care
Secondary prevention practices
Primary prevention practices

Improved survival from MI
Reduced MI, stroke at young ages


Risk Factor Trends in US
Risk Factor

Years* Prevalence

Current

Smoking

1965

42%

20%

Hypertension

1960-2

37%

20%

Cholesterol > 240

1960-2

32%

18%

Diabetes

1960-2

3%

6%

* Reported in MMWR 1999;48(30):649-656

Reduction in CVD Death Rate in US
[Primary Prevention]

[Secondary Prevention]

Pre-1985 due largely to
lifestyle changes
• Smoking cessation
• Decreased dietary fat
intake, lower
cholesterol in
population

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


CHD Trends

McGovern et al, Circulation 2001;104:19-24

Epidemiologic Transition
in East Asia


Estimated deaths per 100,000 population, 2004

Communicable, maternal,
perinatal, nutritional conditions
Infectious, parasitic diseases
Non-communicable diseases
Cardiovascular diseases
Ischemic heart disease
Cerebrovascular disease
Lung cancer
Life expectancy male/female

Cam
604

VN
143

China
73

ROK
30

303
81
33
420
422
526
174
201
246
61
83
55
47
74
138
8
15
29
59/65 69/75 72/75

15
488
170
41
98
36
75/82


Changing Distribution of the Causes of

Death in Peoples Republic of China
Proportion of deaths (%)

100

Unknown
Injury
Other non-communicable diseases
Chronic obstructive pulmonary disease
Cerebro-cardiovascular disease
Cancer
Maternal and perinatal conditions
Communicable diseases

80
60
40
20
0
1973

2005

Year
Yang. Lancet, 2008



CV Risk Factors Vietnam
Mixed Urban and Rural Populations

Risk Factor

Year

Men

Smoking tobacco

2003 34.8%

1.8%

Cholesterol ≥ 6.2 mmol/L

2001

6.5%

11.7%

Diabetes age 55-64
age ≥ 65
SBP ≥140 or DBP ≥90 mmHg

2001 7.6%
2001 11.5%
2002 18.0%

12.4%
18.2%

9.8%

Physical inactivity

2003

8.8%

7.7%

Women