Lifestyle and CVD risk

Size: px

Start display at page:

Download "Lifestyle and CVD risk"

Peter Armstrong
6 years ago
Views:

1 Lifestyle and CVD risk

2 1 Copyright 2017 by Sea Courses Inc. All rights reserved. No part of this document may be reproduced, copied, stored, or transmitted in any form or by any means graphic, electronic, or mechanical, including photocopying, recording, or information storage and retrieval systems without prior written permission of Sea Courses Inc. except where permitted by law. Sea Courses is not responsible for any speaker or participant s statements, materials, acts or omissions

3 Acknowledgments/Disclosures Speaking: HT Canada, Sea Courses, Université Laval et McGill Consulting Insurance : La Capitale, SSQ-Ass, SSQ-Vie et l Union -Vie Guidelines : Diagnosis et CV risk stratification, Canadian Hypertension Guidelines Continuous Professional Development : AAIM,CCS 2

4 Mitigating Potential Bias The information presented is based on recent information that is explicitly evidence-based and is based on CCS and HT Canada Guidelines,

5 Lifestyle and CVD Risk After participating to this session, the attendees will recognise lifestyle as «primordial» CVD risk factors. distinguish «alleged and proven» links between lifestyle and CVD support lifestyle modification in clinical practice as the Rx for classical ( primary ) CVD risk factors. No potential conflicts of interest G.T. D.D

6 Are other risk factors equally or more effective at predicting CVD Genetics Age Gender Lifestyle Social status Physical activity Alcohol X Smoking Waist/ hip-ratio BMI Metabolic factors Lipids Glucose Haemodynamic factors Blood pressure Heart rate Preclinical desease Atherosclerosis Endothelial dysfunction Vascular stiffness LV hypertrophy LV dysfunction CV disease MI Stroke CV death G.T. D.D Olsen, et al. Current Vascular Pharmacology, 2010, 8,

7 Overview Risk Factors Success story Smoking Stress management Physical Exercise Nutrition G.T. D.D

8 CHD Mortality Rates in Men < 65 Years Old Finland USA United Kingdom Hungary France Japan G.T. D.D Mortality from ischaemic heart disease, men 0-64 years. Source: WHO HFA database. 7

9 Contribution of Risk Factors to Burden of Disease Mortality* Percentage of Mortality Attributable to Risk Factors *Based on The World Health Report Yach et al. JAMA. 2004;291: G.T. D.D

10 Lifestyles & Characteristics Associated with Increased Risk of Future CHD events Lifestyles «Treatable/Disease» Non modifiable Diet high in saturated fat, cholesterol and calories Tobacco smoking Excess alcohol consumption Low physical activity Physical inactivity Elevated blood pressure Elevated LDL-cholesterol Low HDL-cholesterol Elevated triglycerides Hyperglycaemia/Diabetes Obesity Thrombogenic factors Age Sex Family history of premature CHD or other atherosclerotic disease at early age (man <55 years) (woman <65 years) Personal history of CHD or other atherosclerotic disease G.T. D.D

11 The Finnish experience Some facts: 1960 High initial population CVD and hypertension rates Some of the key actions Some monitoring and surveillance Part of a pilot (North Karelia) and then national program to reduce CVD Multi sector collaboration Regulation (warning labels) Strong armed voluntary reduction in salt Salt substitute (Pan salt) Major newspaper engagement Strong key opinion leaders G.T. D.D

Finland: Serum Cholesterol 1972-1992 1972 > 1992

12 Finland: Serum Cholesterol > years 700/ > 300/ G.T. D.D

13 Observed and predicted decline in mortality from ischaemic heart disease in men aged in Finland Vartiainen J et al. BMJ Vol 309 July 2, 1994 G.T. D.D

14 Smoking Quitting at any age is most beneficial G.T. D.D

15 Quitting at Any Age Increases Life Expectancy Cigarette Smokers Non-smokers Stopped Age % Survival From Age % - 30% % (60y) - 10 years Years Quitting at a younger age is most beneficial G.T. D.D Doll R et al. BMJ. 2004;328:

16 Physicians and Smoking cessation counselling Express empathy, Offer Help Nicotine replacement Rx. Bupropion Varenicline G.T. D.D

Average number of cigarettes smoked per day by

- 37% household and workplace smoking restrictions

Significantly higher than estimate for previous

17 Average number of cigarettes smoked per day by household and workplace Men: - 39% Women: - 37% Average number of cigarettes smoked per day by household and workplace smoking restrictions and sex, employed daily smokers aged 18 to 54, Canada excluding territories, Data source: 2003 Canadian Community Health Survey * Significantly higher than estimate for previous category(- ies) (p < 0.05) G.T. D.D

18 Admissions, Acute MI Helena, Minnesota, (Scott County), USA Helena Outside Helena Year Admissions for acute myocardial infarction during 6 month periods, June-November 2002 before, during, and after the smoke-free ordinance. (Ordinance did not apply outside Helena). The ordinance was implemented on June 5th, 2002 and then revoqued. Sargent RP Shepard, Robert M, Glantz SA. Reduced incidence of admissions for myocardial infarction associated with public smoking ban: before and after study. BMJ 2004;328: G.T. D.D

19 Risk Factor Stress / Physical Exercise G.T. D.D

20 G.T. D.D

21 Longevity and # heart beats (10,000,000,000) / day Adapted. Levine H.j» JACC 1997 ; 30 : GT, jan 2008 G.T. D.D

22 Longevity and # heart beats G.T. D.D

23 Physical Exercise Meta-analysis: dose-response relation between physical activity and risk of coronary heart disease. The thick blue line represents a fitted curve and the thin blue lines the confidence intervals. (From Sattelmair J, Pertman J, Ding EL, et al: Dose response between physical activity and risk of coronary heart disease: A meta-analysis.circulation 124:789, 2011.) G.T. D.D

24 Risk Factor Nutrition G.T. D.D

25 Risk Factor CHOLESTEROL G.T. D.D

26 «Normal» cholesterol Humans, NA LDL. C Physiologic LDL-C from receptor studies :.66 Guinea Pig Rat Sheep Cow Camel Rabbit Pig Average Adults New borns 25

27 Change of Diet Pattern Traditional Low fat G.T. D.D

28 Dietary Prevention of CHD Finnish mental hospital ( ) Serum Cholesterol over a period of 10 years Practically total replacement of dairy fats by vegetable oils in the diets of these two hospitals G.T. D.D Osmo Turpeinen, et al. Journal of Epidemiology Vol 8. No 2;

29 Dietary Prevention of CHD Finnish mental hospital ( ) First period Second period Hospital N Experimental Diet Normal Diet Hospital K Normal Diet Experimental Diet Age-ajusted Death Rates from Coronary Heart Disease per Person - Years - Males Normal Diet CHD Experimental Diet Hospital N 13,0 5,7 Hospital K 15,2 7,5 N and K, mean 14,1 6,6 «Practically total replacement of dairy fats by vegetable oils in the diets of these two hospitals The total fat consumption should be reduced from the present high levels of 40-45% of total food energy to 35% or even to 25% of total food energy. Less saturated fats.» Less saturated fats G.T. D.D Osmo Turpeinen, et al. Journal of Epidemiology Vol 8. No 2;

Mediterranean Diet Dietary Patten http://www.

30 Mediterranean Diet Dietary Patten G.T. D.D

31 Mediterrean Diet (Post MI) Lyon Heart Study Cumulative survival without nonfatal infarction, without major secondary end points, and without minor secondary end points. G.T. D.D de Lorgeril et al. (Circulation. 1999;99:

32 Lyon Heart Study Event Rate (%) Control diet Mediterranean diet -56% p= % p= % p= % p= Death Cardiac Mortality Non Fatal MI Cancer G.T. D.D de Lorgeril et al. (Circulation. 1998;158 :1161; Circulation 1999;99. 31

33 From Science to Action! G.T. D.D

Primary Prevention of CV Disease with a Mediterranean Diet PREMIMED Study A total of 7447 persons were enrolled (age range, 55 to 80 years); 57% were women.

34 Primary Prevention of CV Disease with a Mediterranean Diet PREMIMED Study A total of 7447 persons were enrolled (age range, 55 to 80 years); 57% were women. The two Mediterranean-diet groups had good adherence to the intervention, according to selfreported intake and biomarker analyses. free provision of extra-virgin olive oil, mixed nuts, or small nonfood gifts. G.T. D.D Estruch et al. N ENGL J MED 368;14 NEJM.ORG APRIL 4,

35 Mediterranean diet Recommended Olive oil * Tree nuts and peanuts Fresh fruits Vegetables Fish (especially fatty fish), seafood Legumes Sofrito White meat Instead of red meat Wine with meals (optionally, only for habitual drinkers) Discouraged Soda drinks Commercial bakery goods, sweets, and pastries Spread fats Red and processed meats Recommended Low-fat dairy products Bread, potatoes, pasta, rice Fresh fruits Vegetables Lean fish and seafood Low-fat diet (control) Goal 4 tbsp/day 3 servings/wk 3 servings/day 2 servings/day 3 servings/wk 3 servings/wk 2 servings/wk 7 glasses/wk Goal <1 drink/day <3 servings/wk <1 serving/day <1 serving/day Goal 3 servings/day 3 servings/day 3 servings/day 2 servings/day 3 servings/wk Discouraged Vegetable oils (including olive oil) 2 tbsp/day Commercial bakery goods, sweets, and pastries 1 serving/wk Nuts and fried snacks 1 serving /wk Red and processed fatty meats 1 serving/wk Visible fat in meats and soups. Always remove Fatty fish, seafood canned in oil 1 serving/wk Spread fats 1 serving/wk Sofrito 2 servings/wk * Extra Virgin Olive Oil: EVOO G.T. D.D Estruch et al. N ENGL J MED 368;14 NEJM.ORG APRIL 4,

36 Primary Prevention of CV Disease with a Mediterranean Diet EVOO: Extra Virgin Olive Oil G.T. D.D N ENGL J MED 368;14 NEJM.ORG APRIL 4,

37 Primary Prevention of Metabolic syndrome with a Mediterranean Diet MetS Reversion MetS Incidence MetS: Metabolic Syndrome G.T. D.D Arch Intern Med. 2008;168(22):

38 Cumulative diabetes free-survival MedDiet + MedDiet + Traditional Salas-Salvadó J. et al. Reduction in the Incidence of Type 2 Diabetes With the Mediterranean Diet. Diab Care, volume 34, G.T. D.D

39 Incidence of diabetes or cardiovascular end point, % Traditional Salas-Salvadó J. et al. Reduction in the Incidence of Type 2 Diabetes With the Mediterranean Diet. Diab Care, volume 34, G.T. D.D

40 Primary Prevention of CV Disease with a Mediterranean Diet LFD: Low Fat Diet; Med-Diet : with Olive oil; Med Diet with Nuts G.T. D.D Pharmacological Research 65 (2012)

41 Primary Care Applicability G.T. D.D

42 Theoretical famework «suggested» for treatment of obesity G.T. D.D Source: The ESC Handbook. Preventive Cardiol p

Time required for the practitioner to fully implement practice guidelines developed by learned societies 21,7 hours / day On average, a family physician spends Acute care Chronic care Preventive care

43 Time required for the practitioner to fully implement practice guidelines developed by learned societies 21,7 hours / day On average, a family physician spends Acute care Chronic care Preventive care 3,7 h 3 h 1,3 h 8 hours If he had to follow all clinical practice guidelines, he would spend Acute care Chronic care Preventive care 3,7 h 10,6 h 7,4 h 21,7 hours From Yarnall and Coll Cited in Profession Santé, Janvier 2015, Volume 1, No. 1 G.T. D.D

44 Change4LIFE Initiative in the United Kingdom G.T. D.D

45 Study desing A prospective single centered randomized controlled trial. New guidelines for secondary prevention in coronary artery disease were distributed by mail and presented at a common lecture for all general practitioners and specialists in 1995 Two primary health care clusters were matched and randomised to Intervention (I) or Control (C) Pr Gunilla Hedlin,Center for Allergy Research 44

46 Trial profile 45

47 Secondary preventive local guidelines for patients with CHD in 1995,Target goals : Total cholesterol < 5.0 mmol LDL-cholesterol < 3.5 mmol/l HDL-cholesterol > 1.0 mmol/l Tot chol 6,4 + 1,1 LDL-chol 4,2 + 1,0 F-Triglycerids <2.3 mmol/l Stop smoking 24 % smokers Diastolic blood pressure <95 mmhg) Blood sugar control Improved Quality of life by healthy food intake, weight reduction, increased physical activity and stress reduction 46

48 Result after ten years 44 % of the included patient in the control group had deceased after ten years as compared to 22 % in the intervention group (p= ; log rank test). Patients treated by a specialist deceased at a rate comparable to the intervention group (23%). 47

The CHAMP Initiative % 100 80 60 40 20 0 12% 6% Guideline Intervention Use 78% 58% Pre-CHAMP Aspirin Statin 4% Beta-blocker ACE Inhibitor 92% 86% 64% 61% 56% Post-CHAMP (1 year) CCB The UCLA Medical

49 The CHAMP Initiative % % 6% Guideline Intervention Use 78% 58% Pre-CHAMP Aspirin Statin 4% Beta-blocker ACE Inhibitor 92% 86% 64% 61% 56% Post-CHAMP (1 year) CCB The UCLA Medical Center s Cardiac Hospitalization Atherosclerosis Management Program (CHAMP) increases guideline intervention and reduced recurrent and myocardial infarction. G.T. D.D Fonarow GC et al. Am J Cardiol 2001;87:

% CHAMP study: Death or recurrent MI The UCLA Medical Center s Cardiac Hospitalization Atherosclerosis Management Program (CHAMP) increases guideline

50 % CHAMP study: Death or recurrent MI The UCLA Medical Center s Cardiac Hospitalization Atherosclerosis Management Program (CHAMP) increases guideline intervention and reduced recurrent and myocardial infarction % Pre-CHAMP 6.4% Post-CHAMP G.T. D.D Fonarow GC et al. Am J Cardiol 2001;87:

51 Lifestyle and CVD Risk After participating to this session, the attendees will recognise lifestyle as «primordial» CVD risk factors. distinguish «alleged and proven «links between lifestyle and CVD support lifestyle modification in clinical practice as the Rx for classical CVD risk factors.. G.T. D.D

52 Lifestyle and CVD risk 51

Mediterranean Diet: Miracle or Mirage. Edwin Cox, M.D.

Mediterranean Diet: Miracle or Mirage Edwin Cox, M.D. The Mediterranean Diet Unique Distinction The only major diet whose effectiveness has been demonstrated in controlled trials In subjects with a first