Decreasing Risk of Developing Cardiovascular Disease Jill Birnbaum

Decreasing Risk of Developing Cardiovascular Disease Jill Birnbaum, State Advocacy Consultant, National Center, American Heart Association

A complete version of this update is available on our Web site, www. americanheart. org/statistics Click on “Heart Disease and Stroke Statistics — 2006 Update”

Risk Factors • • Tobacco High Blood Pressure High Cholesterol Physical Inactivity Overweight and Obesity Diabetes Nutrition Metabolic Syndrome

Preventing Cardiovascular Disease Risk • Primary Prevention – Individual – Environmental • Secondary Prevention • Heart disease and stroke are disorders with complex etiologies and multiple risk factors, so a multifaceted approach to their prevention is crucial to success.

Policy and Environmental Change • We need to create policy and environmental changes that will support behavior change and risk factor prevention and control. • To support behavior change, risk factor control, and uniform access to high quality health care, heart disease and stroke prevention programs must address policy, environmental, and systems-level changes in multiple settings.

Preventing Cardiovascular Disease Risk • In direct contrast with conventional thinking, 80% to 90% of patients with coronary heart disease have at lease one conventional risk factor • Although research on nontraditional risk factors and genetic causes of heart disease is important, clinical medicine, public health policies, and research efforts must place significant emphasis on the four conventional risk factors and the lifestyle behaviors causing them to reduce the epidemic of coronary heart disease.

Trends in Cardiovascular Risk Factors in the U. S. Population Aged 20 -74 NHES: 1960 -62, NHANES: 1971 -75 to 1999 -2000 Source: JAMA 2005. 293: 1868 -74.

Tobacco • Mortality – From 1997– 2001, an estimated 437, 902 Americans died each year of smokingrelated illnesses – 34. 7 percent of these deaths were cardiovascular-related. – Cigarette smoking results in a two-to-threefold risk of dying from CHD. – An estimated 35, 052 nonsmokers die from CHD each year as a result of exposure to environmental tobacco smoke.

Tobacco • Primary prevention goal – Complete cessation – No exposure to secondhand smoke

Tobacco • Prevention – Individual Stop smoking u Eliminate exposure to secondhand smoke u – Environmental Change: Increasing the price of cigarettes through tobacco tax increases u Establish smokefree workplace laws u Support tobacco control prevention and treatment programs u

Tobacco • The impact to CVD in the first year of making all workplaces smoke free: – 1540 myocardial infarctions and 360 strokes would be averted – Health care consumers would save $48. 6 million in direct medical costs. • And, by year seven: – More than 6250 cumulative myocardial infarctions would have been averted. – More than 1270 strokes would have been averted. – Total averted medical costs of $280 million, of which $132 million (or 61%) are from former passive smokers.

High Blood Pressure • Nearly one in three adults has HBP. • The prevalence of hypertension in blacks in the United States is among the highest in the world. • Listed as a primary or contributing cause of death in about 277, 000 deaths in 2003. • The estimated direct and indirect cost for HBP in 2006 is $63. 5 billion.

High Blood Pressure • Primary prevention goal – Goal: <140/90 mm Hg; <130/85 mm Hg if renal insufficiency or heart failure is present; – Or <130/80 mm Hg if diabetes is present.

High Blood Pressure • Promote healthy lifestyle modification – Advocate weight reduction – Reduction of sodium intake – Consumption of fruits, vegetables, and low-fat dairy products – Moderation of alcohol intake – Physical activity

High Blood Cholesterol A fat-like substance found in animal tissue and carried in the blood. Dietary cholesterol is present only in foods from animal sources such as whole milk dairy products, meat, fish, poultry, animal fats and egg yolks. Build-up (plaque) in a blood vessel

High Blood Cholesterol • Prevalence – About 10 percent of adolescents ages 12– 19 have total cholesterol levels exceeding 200 mg/d. L. – Almost 100 million American adults have total blood cholesterol above 200 mg/d. L.

High Blood Cholesterol • Prevention – Eat foods low in saturated fat, trans fat and cholesterol. – Lose weight if you need to. – Exercise for a total of at least 30 minutes on most or all days of the week. – Some people may also need to take medicine, because changing their diet isn't enough.

High Blood Cholesterol • Aftermath – Less than half of persons who qualify for any kind of lipid-modifying treatment for CHD risk reduction are receiving it. – Less than half of even the highest-risk persons, those who have symptomatic CHD, are receiving lipid-lowering treatment – Only about a third of treated patients are achieving their LDL goal; less than 20 percent of CHD patients are at their LDL goal.

Physical (In)Activity

Physical Inactivity • Prevalence – 31. 3 percent of U. S. adults age 18 and older engage in any regular leisure-time physical activity (PA). – The relative risk of CHD associated with physical inactivity ranges from 1. 5 to 2. 4, an increase in risk comparable to that observed for high blood cholesterol, high blood pressure or cigarette smoking.

Physical Inactivity • Goal: At least 30 minutes of moderate-intensity physical activity for adults. • At least 60 minutes a day for children.

Physical Inactivity • We cannot tell our citizens to walk and bike when there is no safe or welcoming place to pursue these activities that promote heart health. • Promoting healthy and walkable community environments is essential both for personal health and for the long -term health of our communities.

Evidence Based Physical Inactivity Interventions • Support a comprehensive physical activity program in school – School-based physical education (the cornerstone) u Require 150 minutes per week of physical education in grades K-6. u Require 225 minutes per week of physical education in middle school. u Require physical education for graduation. u Do not allow waivers and substitutions for physical education. u Develop quality physical education standards at the state level. u Create PE Coordinators at the State Level – Federal – NCLB/ESEA Policy

Evidence Based Physical Activity Interventions • Support a comprehensive physical activity program in school – Support Physical Activity Before, After, and During School – Support physical activity that is incorporated into the school day through elementary school recess, structured physical activity in classrooms, physical activity breaks, physical activity clubs, and special events. – Promote walk/bike to school programs and the use of safe, well-maintained and close-to-home sidewalks, bike paths, trails, and recreation facilities.

Evidence Based Physical Inactivity Interventions • Community-wide campaigns, including point-of-decision prompts http: //www. do-groove. com/

Evidence Based Physical Activity Interventions • Creation of or enhanced access to places for physical activity combined with informational outreach activities • Street-scale urban design and land use policies and practices • Community-scale urban design and land use policies and practices

Overweight and Obesity • Prevalence – An estimated 9. 2 million children and adolescents ages 6– 19 are considered overweight or obese. – Over 10 percent of preschool children ages 2 – 5 are overweight, up from 7 percent in 1994. – In 2003, an estimated 136, 500, 000 American adults were overweight, and 64, 000 were obese. – Since 1993, the prevalence of those who are obese increased over 61 percent.

Obesity Trends* Among U. S. Adults BRFSS, 1985 (*BMI ≥ 30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%– 14%

Obesity Trends* Among U. S. Adults BRFSS, 1990 (*BMI ≥ 30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%– 14%

Obesity Trends* Among U. S. Adults BRFSS, 1995 (*BMI ≥ 30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%– 14% 15%– 19%

Obesity Trends* Among U. S. Adults BRFSS, 2000 (*BMI ≥ 30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 10%– 14% 15%– 19% ≥ 20%

Obesity Trends* Among U. S. Adults BRFSS, 2005 (*BMI ≥ 30, or ~ 30 lbs overweight for 5’ 4” person) No Data <10% 29% ≥ 30% 10%– 14% 15%– 19% 20%– 24% 25%–

Obesity • Impact – Obesity was associated with nearly 112, 000 excess deaths – Abdominal obesity is an independent risk factor for ischemic stroke in all racial and ethnic groups

“the first generation where children will die before their parents” International Congress on Obesity. August 2002 -Actually, 8 million children and adolescents are overweight - Over the last two decades the rates for overweight adolescents have tripled. -Based on current trends 1 in 3 children born in the year 2000 will develop Type II Diabetes. -A National Security Issue

Obesity • Initiate weight-management program through caloric restriction and increased caloric expenditure as appropriate. • Many obese and overweight people may have difficulty losing weight, but by losing even as few as 10 pounds, you can lower your heart disease risk.

The Search for Evidence Based Obesity Interventions • • • School-based interventions Worksite interventions Healthcare system interventions • Community-wide interventions

Diabetes Mellitus • Prevalence – In 2003, the prevalence of physiciandiagnosed diabetes was 14, 100, 000; the prevalence of undiagnosed diabetes was 6, 000. – Since 1990, the prevalence of those diagnosed with diabetes increased 61 percent.

Diabetes Mellitus • Mortality – At least 65 percent of people with diabetes mellitus die of some form of heart or blood vessel disease. – Heart disease death rates among adults with diabetes are two-to-four times higher than the rates for adults without diabetes.

Diabetes Mellitus • First step is diet and exercise. • Second-step therapy is usually oral hypoglycemic drugs. • Third-step therapy is insulin.

Nutrition • The Economic Research Service of the USDA suggests that the average daily calorie consumption in the United States increased by 12 percent between 1985 and 2000, or roughly 300 calories. • Between 1977 and 1996, portion sizes for key food groups grew markedly in the United States, not only at fast-food outlets but also in homes and at conventional restaurants.

Nutrition • Impact – Each year over $33 billion in medical costs and $9 billion in lost productivity due to heart disease, cancer, stroke and diabetes are attributed to diet.

Nutrition • Consumption of a variety of fruits, vegetables, grains, low-fat or nonfat dairy products, fish, legumes, poultry, and lean meats. • Match energy intake with energy needs and make appropriate changes to achieve weight loss when indicated. • Modify food choices to reduce saturated fats (<10% of calories), cholesterol (<300 mg/d), and trans-fatty acids by substituting grains and unsaturated fatty acids from fish, vegetables, legumes, and nuts. • Limit salt intake • Limit alcohol intake among those who drink.

Evidence Based Nutrition Interventions • School-based nutrition programs; • Food and beverage advertising to children; and • Community approaches to increase fruit & vegetable intake

Metabolic Syndrome • Metabolic syndrome (Met. S) is characterized by a group of metabolic risk factors in one person. • The syndrome is associated with obesity and insulin resistance. • Metabolic syndrome is considered a clustering of metabolic complications of obesity.

Metabolic Syndrome • An estimated 1 million 12– 19 -year-old adolescents in the United States have Met. S, or 4. 2 percent overall • An estimated 47 million U. S. residents have Met. S. The age-adjusted prevalence of Met. S for adults is 23. 7 percent. • People with Met. S are about two times more likely to have prevalent CHD than those without the syndrome after adjusting for established risk factors.

Bottom Line • Primary prevention of CVD risk factors can help prevent 80 percent of coronary heart disease and 90 percent of type 2 diabetes

Secondary Prevention of Cardiovascular Disease • There is a growing body of evidence confirms that aggressive comprehensive risk factor management improves survival, reduces recurrent events and the need for interventional procedures, and improves the quality of life • The secondary prevention patient population includes those with established coronary and other atherosclerotic vascular disease, including peripheral arterial disease, atherosclerotic aortic disease and carotid artery disease.

Components of Secondary Prevention Cigarette smoking cessation Blood pressure control Lipid management to goal Physical activity Weight management to goal Diabetes management to goal Antiplatelet agents / anticoagulants Renin angiotensin aldosterone system blockers Beta blockers Influenza vaccination

Cigarette Smoking Recommendations Goal: Complete Cessation and No Exposure to Environmental Tobacco Smoke • Ask about tobacco use status at every visit. • Advise every tobacco user to quit. • Assess the tobacco user’s willingness to quit. • Assist by counseling and developing a plan for quitting. • Arrange follow-up, referral to special programs, or pharmacotherapy (including nicotine replacement and bupropion. • Urge avoidance of exposure to environmental tobacco smoke at work and home.

Blood Pressure Control Recommendations Goal: <140/90 mm Hg or <130/80 if diabetes or chronic kidney disease Blood pressure 120/80 mm Hg or greater: · Initiate or maintain lifestyle modification: weight control, increased physical activity, alcohol moderation, sodium reduction, and increased consumption of fresh fruits vegetables and low fat dairy products Blood pressure 140/90 mm Hg or greater (or 130/80 or greater for chronic kidney disease or diabetes) · As tolerated, add blood pressure medication, treating initially with beta blockers and/or ACE inhibitors with addition of other drugs such as thiazides as needed to achieve goal blood pressure

Lipid Management Recommendations For all patients Start dietary therapy (<7% of total calories as saturated fat and <200 mg/d cholesterol) Adding plant stanol/sterols (2 gm/day) and viscous fiber (>10 mg/day) will further lower LDL Promote daily physical activity and weight management. Encourage increased consumption of omega-3 fatty acids in fish or 1 g/day omega-3 fatty acids in capsule form for risk reduction.

Physical Activity Recommendations Goal: 30 minutes 7 days/week, minimum 5 days/week Assess risk with a physical activity history and/or an exercise test, to guide prescription Encourage 30 to 60 minutes of moderate intensity aerobic activity such as brisk walking, on most, preferably all, days of the week, supplemented by an increase in daily lifestyle activities Advise medically supervised programs for high-risk patients (e. g. recent acute coronary syndrome or revascularization, HF)

Weight Management Recommendations Goal: BMI 18. 5 to 24. 9 kg/m 2 Waist Circumference: Men: < 40 inches Women: < 35 inches Assess BMI and/or waist circumference on each visit and consistently encourage weight maintenance/ reduction through an appropriate balance of physical activity, caloric intake, and formal behavioral programs when indicated. If waist circumference (measured at the iliac crest) >35 inches in women and >40 inches in men initiate lifestyle changes and consider treatment strategies for metabolic syndrome as indicated. The initial goal of weight loss therapy should be to reduce body weight by approximately 10 percent from baseline. With success, further weight loss can be attempted if indicated. *BMI is calculated as the weight in kilograms divided by the body surface area in meters 2. Overweight state is defined by BMI=25 -30 kg/m 2. Obesity is defined by a BMI >30 kg/m 2.

Diabetes Mellitus Recommendations Goal: Hb A 1 c < 7% Lifestyle and pharmacotherapy to achieve near normal Hb. A 1 C (<7%). Vigorous modification of other risk factors (e. g. , physical activity, weight management, blood pressure control, and cholesterol management as recommended). Coordinate diabetic care with patient’s primary care physician or endocrinologist. I (C) Hb. A 1 c = Glycosylated hemoglobin

Antiplatelet Agents / Anticoagulation Recommendations

Renin-Angiotensin-Aldosterone System (RAAS) Blockers Recommendations

b-blocker Recommendations

Influenza Vaccination Patients with cardiovascular disease should have influenza vaccination

The Need to Implement Secondary Prevention • Multiple studies of the use of these recommended therapies in appropriate patients continue to show that many patients in whom therapies are indicated are not receiving them in actual clinical practice. • The AHA and ACC urge that in all medical care settings where these patients are managed that programs to provide practitioners with useful reminder clues based on the guidelines, and continuously assess the success achieved in providing these therapies to the patients who can benefit from them be implemented. • Encourage that the AHA’s Get With the Guidelines and/or ACC’s Guidelines Applied to Practice Programs be instituted to identify appropriate patients for therapy

AHA GWTG Program GWTG is a national initiative of the AHA to improve guidelines adherence in patients hospitalized with cardiovascular disease. GWTG uses collaborative learning sessions, conference calls, e-mail and staff support to assist hospital teams improve acute and secondary prevention care systems. A web-based Patient Management Tool is used for point of care data collection and decision support, on-demand reporting, communication and patient education.

Secondary Prevention Conclusions • Evidence confirms that aggressive comprehensive risk factor management improves survival, reduces recurrent events and the need for interventional procedures, and improves the quality of life for these patients. • Every effort should be made to ensure that patients are treated with evidence-based, guideline recommended, life-prolonging therapies in the absence of contraindications or intolerance.

Quality and Availability of Care Policy • Promote Adherence to Clinical Guidelines & Treatment Protocols • Promote Quality and Performance Indicators • Promote Access to Health Coverage • Monitor Pay-for-quality and Non-financial Incentives • Monitor Drug Formulary Policy • Monitor Health Information Technology

What should we be working towards in HIT? AHA HIT Checklist 1 Includes Clinical Decision Support Tool (GWTGs) 2 Committees/Councils and TAPs include chronic care representation & guidelines developer Encourage the funding and evaluation of EHR and PHR studies 3 4 Ensure patient centric language is included 5 Activities at state level should not conflict with federal activities by the HHS, AHIC or AHRQ. Encourages interoperability and connectivity 6

What should we be working towards in HIT? (Cont. ) AHA HIT Checklist 7 8 Additional research on how consumer incentives can be used to encourage beneficiaries to utilize PHRs Minimize potential adverse affect of HIPAA and privacy to clinical research 9 10 Watch for P 4 P language and refer to P 4 Q statement NFI statement (upcoming) 11 Cost effectiveness (misuse, under use, overuse)

Additional Information Jill Birnbaum State Advocacy Consultant jill. birnbaum@heart. org 952 -278 -3643

&A Q Questions?