40% minimum reduction from

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1 160 Circulatory Disease Mortality Target: Death rates in England Persons under 75 Death / 100,000 population A fall of 44% over 10 years Immortality guaranteed by Target: 40% minimum reduction from /4/5 1995/6/7 1997/8/9 1999/2000/1 2001/2/3 2003/4/5 2005/6/7 2007/8/9 2009/10/11 3 year average. baseline Progress target Source: ONS (ICD ; ICD10 I00-I99)

2 Evolution of Atherosclerosis Genetic Environmental Clinical Events Age (yrs)

3 Coronary Heart Disease Mortality in Beijing Extra deaths Attributable to Risk Factor Changes Cholesterol 77% Diabetes 19% BMI 4% Smoking 1% 642 fewer deaths by treatments AMI treatments 41% Hypertension treatment 24% Secondary prevetion 11% Heart failure 10% Aspirin for Angina 10% Angina: CABG & PTCA 2% Critchley J. Circulation, 2004;110:

4 Billions 2008 $ 900 Forecasting Future CVD in USA Indirect Direct 0 Heidenreich Circ 2011; 123:

5 Emergence of Health Maintenance as the Business of Health Care Eastman Kodak filed for bankrupcy on Jan after 131 years Move from product orientated industry to customer orientated one Asch NEJM 2012;367:888-9

6 Lifetime Management of Atherosclerosis Risk Early intervention pays long term dividends

7 Prevalence of Atherosclerosis (%) Prevalence of Atherosclerosis by Donor Age EEM Area 13.2 mm mm % 60% 71% 85% 20 17% Atheroma Area 8.13 mm 2 32 Year Old Female 0 < Donor Age (years) Tuzcu Circ :

8 Mean maximum carotid IMT (mm) CV Risk Factors in Childhood and Carotid IMT in Adults Risk factors measured at ages 12-18yrs No. of risk factors or 4 P<0.001 Men P<0.001 Women Raitakari et al JAMA 2003;290;

9 Circulation. 2012;126:

10 Adjusted Cumulative Incidence Framingham Heart Study :Lifetime Risk Men 69% 50% 46% 36% Women 2 Major RFs 1 Major RF Elevated RF Not Elevated RF All Optimal RFs 50% 39% % % Attained Age % Lloyd-Jones Circ. 2006; 113:

11 Lifetime Risk of Death from CV Disease Berry NEJM 2012; 366:

12 Age and CV Risk in Diabetes 30 Men 30 Women 25 Men with diabetes Men without diabetes 25 Women with diabetes Women without diabetes Age (years) Age (years) Booth Lancet 2006; 368: 29-36

13 Age-standardized rate of death from any cause (per 100 person-yr) Age-standardized rate of CV events (per 100 person-yr) Independent and Graded Association between GFR and CVD < <15 Estimated GFR (ml/min/1.73m 2 ) Estimated GFR (ml/min/1.73m 2 ) Go et al; NEJM 2004

14 LDL Cholesterol and Coronary Heart Disease among Black Subjects by PCSK9 142X or PCSK9 679X Allele Frequency (%) Coronary Heart Disease (%) No Nonsense Mutation (n=3278) 50 th Percentile 12 8 P= % PCSK9 142X or PCSK9 679X (N=85) 28% No Yes LDL Cholesterol in Black Subjects (mg/dl) PCSK9 142X or PCSK9 679X Cohen NEJM 2006; 354:

15 ESC CV Prevention Guidelines 2012 European Heart Journal 2012; 33:

16 10 year risk 10 year risk 10 year risk 10 year risk Importance of Lifetime Risk 50% 40% 30% Average male nonsmoker 50% 40% 30% Average female non-smoker CHD CVD JBS2(e) 20% 20% 10% 10% 0% 0% 50% 40% Average male smoker 50% 40% Average female smoker 30% 30% 20% 20% 10% 10% 0% Age 0% Age

17 Short Term v. Lifetime Risk in USA Non-smoking men <45yrs All women <65yrs <10% 10yr CHD Risk Marma Circ 2009;120: % of US adults (87,000,000) have low (<10%) 10yr and high lifetime ( 39%) risk Marma Circ Cardiothoracic Qual Outcomes 2010;3:8-14

18 Joint British Societies (JBS3): CV Risk Management Lifetime risk calculator New metrics for communication Heart age Age at 1st CV event

19 New UK JBS3 Lifetime Risk Calculator

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22 How early should prevention start?

23 Benefit of Smoking Cessation

24 Obesity in the Young 13 year old boy weighing 11.2kg more than normal runs 33% increased probability of a CV event < 60Yrs The commonest instruments of suicide are a knife and fork Martin Fischer

25 Juonala NEJM 2011; 365:

26 Responsibility for Childhood Obesity? 80 Who is at fault for obesity? Who is reponsible for addressing it? Parents Food and drink manufacturers The individual The state Henley Centre (2007) Sell health as a valued commodity

27 No. of excess events No. of excess events Potential Benefit of CV RF treatment in Obesity Excess Total CHD Events Excess Deaths from CHD Average projection Treatment for DBP and LDL Treatment for DBP, LDL and HDL Average projection Treatment for DBP and LDL Treatment for DBP, LDL and HDL Year Year Bibbins-Domingo NEJM 2007; 357:

28 Items (000s) Number of Prescriptions for Statins each Quarter in England 13,000 12,000 11,000 10,000 9,000 8,000 7,000 6,000 5,000 4,000 3,000 2,000 1,000 0

29 Polypill Concept

30 Pletcher JACC 2010; 56: A reasonable next step for ATP IV?.Consider statins for younger persons, perhaps starting at 30 in those with risk factors that convey high lifetime risk (as opposed to 10 yr risk) for CHD

31 Percentage of participants Ideal CV Health: How Often Do We Get There? 1933 participants in Heart SCORE-only 1 with 7 components 100 Race P<0.001 Sex P<0.260 AHA Definition Non smoking BMI <25kg/m 2 Physical Activity Recommended diet Untreated TC <200 mg/dl Untreated BP <120/80 mmhg Untreated FBG <100 mg/dl No. of ideal components Roger Circ 2011; 123: Total (1933) White (1078) Black (855) Women (1268) Men (665)

32 Proportion of published cost-effectiveness ratios Cost Effectiveness of Preventive Interventions Environmental intervention Non-clinical, person-directed intervention Clinical intervention Costsaving <10,000 10,000 to <50,000 50,000 to <100, ,000 to <250, ,000 to <1,000,000 >1,000,000 Increases cost and worsens health Chokshi NEJM 2012;367:295-6

33 Taxation of Food and Drink Sugar, rum and tobacco are commodities which are nowhere necessaries of life, which are become objects of almost universal consumption, and which are therefore extremely proper subjects of taxation. Adam Smith, The Wealth of Nations, 1776 Brownell NEJM 2009;360:

34 CV disease is preventable Life-long Rx likely to be cost-effective and often cost saving Circulation 2011;124:

35 It should be the function of medicine to have people die young as late as possible Ernest L. Wynder M.D.

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