Cardiovascular Disease Prevention: Current Knowledge, Future Directions Daniel Levy, MD Director, Framingham Heart Study Professor of Medicine, Boston University School of Medicine Editor-in-Chief, Journal of the American Society of Hypertension American College of Osteopathic Internists October 18, 2018
Disclosure of Relationships The views and opinions expressed in this presentation are those of the speaker and not necessarily those of the NIH or HHS No relationships with industry
Leading Causes of Death in the US Year 1900 1. Pneumonia/influenza 2. Tuberculosis 3. Diarrhea Life expectancy 48 (m) 51 (f) Today 1. Heart disease 2. Cancer 3. Stroke Life expectancy 75 (m) 80 (f) Source: www.cdc.gov/nchs/data/hestat/preliminarydeaths04_tables.pdf
Naïve Beliefs About Healthy Lifestyles
Cardiovascular Disease Prevention: Current Knowledge, Future Directions Magnitude of the problem Traditional risk factors Emerging risk factors Genetic risk Future directions
The Big Five
Risk of CHD Death According to SBP and DBP in MRFIT 4 3 Systolic Diastolic Relative Risk 2 1 Decile 0 Systolic BP (mm Hg) Diastolic BP (mm Hg) 1 2 3 4 5 6 7 8 9 10 (lowest 10%) (highest 10%) <112 <71 112-71- 118-76- 121-79- 125-81- 129-84- 132-86- 137-89- 142-92- 151 98 Data from Stamler J, Stamler R, Neaton JD. Arch Intern Med 1993; 153: 598-615.
Risk of Stroke Death According to SBP and DBP in MRFIT Relative Risk Decile 9 8 7 6 5 4 3 2 1 0 Systolic BP (mm Hg) Diastolic BP (mm Hg) Systolic Diastolic 1 2 3 4 5 6 7 8 9 10 (lowest 10%) (highest 10%) <112 <71 112-71- 118-76- 121-79- 125-81- 129-84- 132-86- 137-89- 142-92- >151 >98 Data from Stamler J, Stamler R, Neaton JD. Arch Intern Med 1993; 153: 598-615.
CHD Mortality: Prospective Studies Collaboration IHD Mortality (floating absolute risk and 95% CI) 256 128 64 32 16 8 4 2 1 0 120 140 160 180 Usual Systolic Blood Pressure (mm Hg) 80-89 years 70-79 years 60-69 years 50-59 years 40-49 years 256 128 Prospective Studies Collaboration. Lancet. 2002;360:1903-1913. 64 32 16 8 4 2 1 0 70 80 90 100 110 Usual Diastolic Blood Pressure (mm Hg) 80-89 years 70-79 years 60-69 years 50-59 years 40-49 years
Stroke Mortality: Prospective Studies Collaboration Stroke Mortality (floating absolute risk and 95% CI) 256 128 64 32 16 8 4 2 1 0 120 140 160 180 Usual Systolic Blood Pressure (mm Hg) 80-89 years 70-79 years 60-69 years 50-59 years 256 128 Prospective Studies Collaboration. Lancet. 2002;360:1903-1913. 64 32 16 8 4 2 1 0 70 80 90 100 110 Usual Diastolic Blood Pressure (mm Hg) 80-89 years 70-79 years 60-69 years 50-59 years
Hypertension Awareness, Treatment, and Control among Adults in the US NHANES (1999 2006, 2007 2014)
Prevalence of Hypertension Among Adults in the US NHANES 2011 2014
Trends in Prevalence of Hypertension among Adults in the US NHANES 1988 1994, 1999 2006, and 2007 2014
Risk of Death from CHD: In 356,222 Men in the MRFIT Study 6 Year Rate per 1000 12 10 8 6 4 2 0 3 4 <182 182-202 203-220 221-244 >244 Cholesterol Level (mg/dl) Stamler et al. JAMA 1986;256:2823 6 7 11
Risk of Death from Coronary Heart Disease: In 356,222 Men in the MRFIT Study Stamler et al. JAMA 1986;256:2823
Cholesterol and CHD: Seven Countries Study CHD mortality rates (%) 30 25 20 15 10 Northern Europe United States Southern Europe, Inland Southern Europe, Mediterranean Siberia Japan 5 0 100 125 150 175 200 225 250 275 300 325 350 (2.60) (3.25) (3.90) (4.50) (5.15) (5.80) (6.45) (7.10) (7.75) (8.40) (9.05) Verschuren WMM et al. JAMA. 1995;274:131-136. TC mg/dl (mmol/l)
Prevalence of Elevated Cholesterol in Adults in the US National Health and Nutrition Examination Survey (2011 2014)
Trends in Prevalence of Elevated Cholesterol Levels Among Adolescents Age 12-19 in the US NHANES 1988 1994, 1999 2006, and 2007 2014
Trends in Mean Cholesterol Levels in Adults in the US NHANES 1988 1994, 1999 2006, and 2007 2014
Trends in Elevated Cholesterol Levels in Adults in the US NHANES 2011 2012 and 2013 2014
Prevalence of Cigarette Smoking NHIS, 2003 2015; NSDUH, 2003 2015
Prevalence f Diabetes and Pre-Diabetes Among Adults in the US DM: FBG >125 mg/dl Pre-DM: FBG 100-125 Centers for Disease Control and Prevention, National Diabetes Statistics Report, 2014
Trends in Prevalence of Diabetes among Adults in the US NHANES 1988 1994 and 2011 2014
Diabetes Awareness, Treatment, and Control among Adults in the US NHANES 2011 2014
Prevalence of Overweight and Obesity National Health and Nutrition Examination Survey (NHANES) 2011 to 2014
Prevalence of Obesity in Children and Adolescents National Center for Health Statistics
Prevalence of Obesity in Adults NHANES 2011 2014
Trends in Obesity National Center for Health Statistics 19
Prevalence of Obesity in Adults BRFSS, 2015
Prevalence of Obesity in Adults Whites Blacks BRFSS, 2015
Ideal Health Life s healthy 7 Risk factors Lifestyle factors
Ideal Health
Incidence of CVD by the number of ideal health factors Folsom et al. JACC 2011;57:1690
Prevalence of poor, intermediate, and ideal cardiovascular health among US children aged 12-19 years National Center for Health Statistics, NHANES 2013 to 2014
Prevalence of poor, intermediate, and ideal cardiovascular health among US adults National Center for Health Statistics, NHANES 2013 to 2014
Completion of Draft Sequence of the Human Genome June 2000 I would be willing to make a prediction that within 10 years, we will have the potential of offering any of you the opportunity to find out what particular genetic conditions you may be at increased risk for, based upon the discovery of genes involved in common illnesses like diabetes, hypertension, heart disease, and so on. Francis Collins, June 26, 2000
Best Career Opportunities 1967 2015 PRECISION MEDICINE!
Precision Medicine Tonight, I'm launching a new Precision Medicine Initiative to bring us closer to curing diseases like cancer and diabetes and to give all of us access to the personalized information we need to keep ourselves and our families healthier. President Obama, State of the Union Address, January 20, 2015
Polymorphisms in 9 Lipid Genes Predict Lipid Levels LDL APOB APOE HMGCR LDLR PCSK9 HDL ABCA1 CETP LIPC LPL Kathiresan et al. N Engl J Med March 20, 2008
Polymorphisms in 9 Lipid Genes Predict Lipid Levels LDL P=2x10-18 HDL P=3x10-24 Kathiresan et al. N Engl J Med March 20, 2008
Polymorphisms in 9 Lipid Genes Predict Risk of CVD Kathiresan et al. N Engl J Med March 20, 2008
Genetically Driven Drug Discovery
PCSK9 Mutations and CHD
Using Genetics to Determine Risk
A Genetic Risk Score for Coronary Artery Disease
Performance of Genetic Risk Scores for Other Diseases A-Fib T2D IBD Breast Cancer
Performance of Genetic Risk Scores for 5 Diseases