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ا�پ�ی�د�م�ی�و�ل�و�ژ�ی ت�ع�ر�ی�ف�

ه�ا�ی� ب�ی�م�ا�ر�ی� ج�ه�ا�ن�ی� ب�ه�د�ا�ش�ت� س�ا�ز�م�ا�ن� گ�ز�ا�ر�ش�ه�ا�ی� ا�ز� ی�ک�ی� ب�ر�ا�س�ا�س�ز�ی�ر�ا�س�ت- ا�خ�ت�ال�ال�ت� م�ج�م�و�ع�ه� ش�ا�م�ل� ع�ر�و�ق�ی� :ق�ل�ب�ی�

•Hypertension (high blood pressure)• Coronary heart disease (heart attack)• Cerebrovascular disease (stroke)• Peripheral vascular disease• Heart failure• Rheumatic heart disease• Congenital heart disease• Cardiomyopathies• Deep vein thrombosis and pulmonary embolism

ع�ر�و�ق�ی ق�ل�ب�ی� ب�ی�م�ا�ر�ی�ه�ا�ی� ت�ع�ر�ی�ف�

پ�ی�ش�گ�ف�ت�ا�ر

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h Ύϫh έΎϤϴΑˬβ ϨΟϭΩήϫέΩϭϦϴϨγ ϡΎϤΗέΩήϴϣϭn ήϣΖ ϠϋϦҨήΗϊ ҨΎη ϭϦϴϟϭ ΰϴϧϥ ήҨέΩΒϠϗ Ϟ ί ϭΖ γ ήϧϭή ϕ ϭήϋh Ύϫh έΎϤϴΑι ϮμΧϪΑ ϗϭήϋ700ΎΗ800Ϫˬϧίϭέn ήϣΩέϮϣ317 ϣ ϗϭήϋ ΒϠϗh Ύϫh έΎϤϴΑΖ ϠϋϪΑήϔϧ Ϫ Ϊ ϧήϴϣ166 ΒϠϗϪΘγ Ζ ϠϋϪΑϥ ΩέϮϣ

Ζ γ .

1., Descriptive epidemiology:= Describing distribution of cardiovascular disease by

means of certain characteristics such as : PERSON (i.e., age, gender, ethnicity) TIME and PLACE

2., Analytic epidemiology= Analyzing relationships between CVD and risk

factors (which elevate the probability of a disease at population level), risk model and multicausal developments

3., Experimental epidemiology/Interventions= Strategies of cardiovascular prevention (primordial,

primary, secondary, tertiary; individual and community levels)

PARTS OF CARDIOVASCULAR EPIDEMIOLOGY

In the world: CVD deaths account for one third of all deaths (25-50% depending on the level of economic development) among which 50%: coronary deaths

CVD made up 16.7 million of global deaths in 2002, among which 7 million due to coronary heart disease, 6 million due to stroke

Distribution of types of CVD in global deaths :Global cardiovascular deaths in 2002: 16.7 millionamong which: coronary heart disease 7.2 million >

stroke 6.0 million > 0.9 million hypertensive heart disease > 0.4 million inflammatory heart disease > 0.3 million rheumatic heart disease > 1.9 million other CVD

DESCRIPTIVE EPIDEMIOLOGY I. DISTRIBUTION PATTERNS IN THE

WORLD

Question: What is the relative amount of CVD in death rates in different age groups?

- Early lesions of blood vessel, atherosclerotic plaques: around 20 years - adult lifestyle patterns usually start in childhood and youth (smoking, dietary habits, sporting behavior, etc.)

- Increase in CVD morbidity and mortality: in age-group of 30-44 years

DESCRIPTIVE EPIDEMIOLOGY II. AGE

PROPORTION OF MORTALITY IN DIFFERENT AGE-GROUPS (MEN)

PROPORTION OF MORTALITY IN DIFFERENT AGE-GROUPS (WOMEN)

Question: What is the relative amount of CVD in death rates in women and men?

- Widespread idea: CVD is often thought to be a disease of middle-aged men.

- Cardiovascular mortality (fatal cases) are more common among men. However, CVD affect nearly as many women as men, albeit at an older age

- Women: special case (WHO, 2004) a., Higher risk in women than men (smoking, high

triglyceride levels) b., Higher prevalence of certain risk factors in women

(diabetes mellitus, depression) c., Gender-specific risk factors (risks for women only)

(oral contraceptives, polycystic ovary syndrome)

DESCRIPTIVE EPIDEMIOLOGY III. SEX

Question: What is the relative amount of CVD in death rates in different ethnic groups?

- In the US: increased cardiovascular disease deaths in African-American and South-Asian populations in comparison with Whites

- Increased stroke risk in African-American, some Hispanic American, Chinese, and Japanese populations

- Migration: Ni-Hon-San Study: Japanese living in Japan had the lowest rates of CHD and cholesterol levels, those living in Hawaii had intermediate rates for both, those living in San Francisco had the highest rates for both

DESCRIPTIVE EPIDEMIOLOGY IV. ETHNICITY

Developed countries: decreasing tendencies (e.g, USA: 30% between 1988-98, Sweden: 42%)

- improvement of lifestyle factors, for example, a decrease of smoking and a higher level of health consciousness in many developed countries

- better diagnostic and therapeutic procedures (e.g., bypass surgeries, hypertension screening, pharmacological treatment of hypertension and hypercholesterinaemia, access to health care)

Developing countries: increasing tendencies- increasing longevity, urbanization, and western

type lifestyle

DESCRIPTIVE EPIDEMIOLOGY VI. WORLD TRENDS

ANALYTIC EPIDEMIOLOGY II. CLASSIFICATION OF RISK FACTORS

Estimated 10-Year CHD Risk in 55-Year-Old Adults According to Levels of Various Risk Factors Framingham Heart Study

A B C DBlood Pressure (mm Hg) 120/80 140/90 140/90 140/90Total Cholesterol (mg/dL) 200 240 240 240HDL Cholesterol (mg/dL) 50 50 40 40Diabetes No No Yes YesCigarettes No No No Yes

5

13

25

58

20

27

37

05

10152025303540

A B C D

Estim

ated

10-

Year

Rat

e (%

)

MenWomen

2.6 4 5.48.4

1.1 2

19.122.4

14.8

27

6.33.5

0

5

10

15

20

25

30

A B C D E F

Est

imat

ed 1

0-Y

ear R

ate

(%)

Men Women

Estimated 10-Year Stroke Risk in 55-Year-Old Adults According to Levels of Various Risk Factors Framingham Heart Study

A B C D E FSystolic BP* 95-105 130-148 130-148 130-148 130-148 130-148Diabetes No No Yes Yes Yes YesCigarettes No No No Yes Yes YesPrior Atrial Fib. No No No No Yes YesPrior CVD No No No No No Yes

Source: Stroke 1991;22:312-318. *BP in millimeters of mercury (mmHg)

2.64 5.4

8.4

1.1 2

19.1

22.4

14.8

27

6.33.5

0

5

10

15

20

25

30

A B C D E F

Est

imat

ed 1

0-Y

ear R

ate

(%)

Men Women

A B C D E FSystolic BP* 95-105 130-148 130-148 130-148 130-148 130-148Diabetes No No Yes Yes Yes YesCigarettes No No No Yes Yes YesPrior Atrial Fib. No No No No Yes YesPrior CVD No No No No No Yes

Estimated 10-year stroke risk in 55-year-old adults according to levels of various risk factors (FHS). Source: Wolf et al., Stroke.1991;22:312-318.

*BP in millimeters of mercury (mmHg)

Offspring CVD Risk by Parental CVD Status: Framingham Study

0

0.5

1

1.5

2

2.5

MEN WOMEN

NONEMATERNALPATERNAL

Risk Ratio

1.0

1.7

2.2

1.0

1.7 1.7

Adjusted for: age, total/HDL Chol. ratio, SBP, smoking, diabetes, BMI

Parental CVD <55 men, <65 Women

Serum Cholesterol

Age: 35-64* Age: 65-94

MenWome

n Men+ Women*84-204

8 422 11

205-23413 5

24 15

235-26414 4

26 17

265-29415 7

23 17

295-1124 26 10

38 32

Risk of Coronary Heart Diseaseby Serum Cholesterol

30-Year Follow-up, The Framingham Study

*Trends Significant at P.001. +P.07.

Age-Adjusted Annual Rate per 1000

Q = serum cholesterol quintile. Kannel WB et al. Am Heart J. 1986;112:825-836.

Multiple Risk Factor Intervention Trial (MRFIT) N=325,346

Correlation Between Serum Cholesterol and CVD Mortality

6-Ye

ar C

VD D

eath

Rat

e Pe

r 100

0

0

5

10

15

20

25

30

Q1

(<182)Q2

(182-202)Q3

(203-220)Q4

(221-244)Q5

(>244)

35-39 years

40-44 years

45-49 years

50-54 years

55-57 years

Serum Cholesterol Quintile (mg/dL)

Untreated Patients

Lifetime Risk of CHD Increases with Serum Cholesterol

0

10

20

30

40

50

60

Perc

ent

Men Women

<200 mg200-239 mg>240 mg

Framingham Study: Subjects age 40 yearsDM Lloyd-Jones et al Arch Intern Med 2003; 1966-1972

34

44

57

19

29

33

Cholesterol

___________________________________________________________________________

_______________________________________________________________________________

Age-adjusted prevalence of Adults age 20 and older with LDL cholesterol of 130 mg/dL or higher, by race/ethnicity and sex (NHANES: 2003-2004). Source: NCHS and NHLBI. NH – non-Hispanic.

32.0 32.0 32.0

39.0

32.0 34.030.0 31.0

05

1015202530354045

Total Population NH Whites NH Blacks MexicanAmericans

Perc

ent o

f Pop

ulat

ion

Men Women

Age-adjusted prevalence of Adults age 20 and older with HDL cholesterol <40 mg/dL, by race/ethnicity and sex (NHANES: 2003-2004). Source: NCHS and NHLBI. NH – non-Hispanic.

25

16

9 97

13

26 28

05

1015202530

Total NH Whites NH Blacks MexicanAmericans

Perc

ent o

f Pop

ulat

ion

Men Women

Trends in mean total serum cholesterol among adults age 20 and older, by race/ethnicity, sex and survey (NHANES : 1988-94, 1999-02 and 2003-04). Source: NCHS and NHLBI. NH – non-Hispanic.

206

204205

204

199

202202

197

201

192

194196

198

200

202204

206

208

NH White NH Black Mexican American

Mea

n Se

rum

Tot

al C

hole

ster

ol

1988-94 1999-02 2003-04

Trends in mean total blood cholesterol among adolescents ages 12-17 by race, sex, and survey (NHES: 1966-70; NHANES: 1971-74 and 1988-94). Source: NCHS and NHLBI.

163

171 170

165

174

155

163161

172

166163

166 168164

156

161

145

150

155

160

165

170

175

180

White Males Black Males White Females Black Females

Mea

n To

tal B

lood

Cho

lest

erol

1976-80 1988-94 1999-02 2003-04

Prevalence of high blood pressure in Adults by age and sex (NHANES: 1999-2004). Source: NCHS and NHLBI.

11.2

37.4

55.4

73.9

23.2

37.549.1

63.669.5

6.4

83.8

18.3

0.010.020.030.040.050.060.070.080.090.0

20-34 35-44 45-54 55-64 65-74 75+

Perc

ent o

f Pop

ulat

ion

Men Women

CHD Risk by Cigarette Smoking. Filter Vs. Non-filter. Framingham Study. Men <55 Yrs.

0

50

100

150

200

250

Total CHD MyocardialInfarction

Non-SmokerReg. Cig. SmokerFilter Cig. Smoker

14-yr. Rate/1000

119

206 210

59

112210

3

2.4

1.8

1.2

0.6

0

(1971) (1989)

Q1 Q2 Q3 Q4 Q5 OverallThin Obese

Risk Factor Sum and Obesity(1971-74) and (1989-93)

Ris

k Fa

ctor

Sum

Risk variables include bottom quintile for HDL-C and top quintiles for cholesterol, SBP, triglycerides and glucose

Framingham Study

Risk factors accumulate with weight gain

Trends in prevalence of overweight among U.S. children and adolescents by age and survey (NHANES, 1971-74, 1976-80, 1988-94 and 2001-2004). Source: Health, United States, 2006, unpublished data. NCHS.

4.3 3.6

6.6 6.4

11.6 11

18.7

16.3

02468

101214161820

6-11 12-19

Perc

ent o

f Pop

ulat

ion

1971-74 1976-80 1988-94 2001-2004

- Systolic blood pressure >140 Hgmm and/or a diastolic blood pressure > 90 Hgmm

- Free of clinical symptoms for many years (screening)

- In most countries, up to 30 percent of adults suffering, increasing with age in civilized countries

- Positive family history- Dietary habits (a high intake of salt, processed food,

low levels of water hardness, high thyramine content of food, alcohol use)

- Modern lifestyle (increased sympathetic activity, psychosocial stress, leading position in job)

ANALYTIC EPIDEMIOLOGY II. CLASSIFICATION OF RISK FACTORS

Development: Rheumatic fever usually follows an untreated beta-haemolytic streptococcal throat infection in children

As a consequence, the heart valves are permanently damaged which may progress to heart failure

Today mostly affects children in developing countries, linked to poverty, inadequacy of health care access

Occurrence: 12 million people currently affected by rheumatic fever and RHD, two-thirds are children (5-15 years), for example: approx. 1 000 000 in Sub-Saharan Africa, 700 000 in South-Central Asia, 176 000 in China, 150 000 in North Africa, 40 000 in Eastern Europe (!)

ANALYTIC EPIDEMIOLOGY IV. RHEUMATIC FEVER AND RHEUMATIC HEART

DISEASE

- Se cholesterol: structure and functioning of blood vessels, atherosclerotic plaques

- Altering functions of cholesterol fractions (LDL: risk, HDL: protection)

- Estrogen: tends to raise HDL-cholesterol and lower LDL-cholesterol, protection for women in reproductive age

- Partially genetic determination of metabolism, partially dependent of nutrition (egg, meats, dairy products)

ANALYTIC EPIDEMIOLOGY V. ABNORMAL BLOOD LIPIDS

- The link between smoking and CVD (mainly CHD) was identified in 1940

- Passive smoking: additional risk- Women smokers: are at higher risk of CHD and CVD

than male smokers - Several mechanisms: damages the endothelium

lining, increases atherosclerotic plaques, raises LDL and lowers HDL, promotes artery spasms, raises oxigen demand of the heart muscle

- Nicotine accelerates the heart rate (HR), and raises blood pressure

ANALYTIC EPIDEMIOLOGY VI. TOBACCO USE

- Regular physical activity: protective factor- Intensity and duration (150 minutes/week

intermediate or 60 minutes/week heavy)- Modernization, urbanization, mechanized transport:

sedentary lifestyle (60% of global population)- Raises CVD risk and also the development of other

risk factors (glucose metabolism, diabetes mellitus, blood coagulation, obesity, high blood pressure, worsening lipid profile)

- Physical activity: helps reduce stress, anxiety and depression

ANALYTIC EPIDEMIOLOGY VII. PHYSICAL INACTIVITY

- Body Mass Index: > 25: overweight, > 30: obesity- A modern ”epidemic”: More than 60% of adults in

the US are overweight or obese, in China: 70 million overweight people

- Elevates the risk of both CVD and diabetes mellitus- Diabetes mellitus: damages both peripheral and

coronary blood vessels-Unhealthy diet: low fruit and vegetable, fiber

content, and high saturated fat intake, refined sugar

ANALYTIC EPIDEMIOLOGY VIII. OBESITY, DIABETES MELLITUS, UNHEALTHY

DIET

- Psychological factors (Type A behavior, hostility)- Depression and CVD: bidirectional linka., depression may increase the risk of CVD and

worsen recovery process b., CVD may induce depression - Low socioeconomic status (SES): a., in developed countries: less educated and lower

SES groups (accumulation of risk factors)b., in developing countries: more educated and

higher SES groups (western lifestyle)

ANALYTIC EPIDEMIOLOGY IX. PSYCHOLOGICAL AND SOCIAL

FACTORS

CMPN = communicable, maternal, perinatal , and nutr it ional diseases

CVD = cardiovascular disease

INJ = injury ONC = other

noncommunicable diseases.

(From Mathers CD, Lopez A , Stein D, et a l : Deaths and disease burden by cause: Global burden of disease est imates for 2001 by World Bank Country Groups, 2005. Disease Control Pr ior i t ies Working Paper 18 [http:/ /www.dcp2.org/file/33/wp18.pdf] . )

FIGURE 1-1   CHANGING PATTERN OF MORTALITY, 1990 TO 2001.