Community Medicine Department Faculty of Medicine University of Indonesia SETYAWATI BUDININGSIH, RETNO ASTI WERDHANI NURI PURWITO ADI

April 4th 2012

DESCRIPTIVE EPIDEMIOLOGY

ANALYTIC EPIDEMIOLOGY

Incidence Prevalence
Triad Epidemiology Host Agent - Environment

Risk Factors

Diagnostic Tools

Holistic Diagnosis (BIOPSYCHOSOSIAL)

CLINICAL EPIDEMIOLOGY (Prognostic Study, Clinical Trial, Meta Analysis)

Therapy, Prognosis

 Cardiovascular

disease is caused by disorders of the heart and blood vessels, and includes coronary heart disease (heart attacks), cerebrovascular disease (stroke), raised blood pressure (hypertension), peripheral artery disease, rheumatic heart disease, congenital heart disease and heart failure.

The

major causes of cardiovascular disease are tobacco use, physical inactivity, and an unhealthy diet.

 Predispose

factors : Age, Gender, Family history, Behavior, Sanitation, etc Risk factors : Obesity/Malnourished, Hypertension Dyslipidemia, Impairment of Glucose Control, and Systemic Inflammation, etc

Clinical

 Smoking

raises risk of atherosclerotic disease and potentiates myocardial infarction (MI) Smoking cessation reduces the risk of MI and mortality by 36%
Smoking

cessation : education about the danger of smoking and intervention with nicotine replacement and bupropion Relapse rate are high in the absence of education and encouragement.

 Hypertension Atherosclerotic

Coronary Heart Disease and Peripheral Vascular Disease Congestive Heart Failure Congenital Heart Disease Valvular Health Disease Cardiac Arrhythmias

 SKRT

2001

6 % HTN at 25-34 yr 15 % HTN at 35-44 yr 43 % HTN at > 55 yr 2/3 uncontrolled HTN patients at > 60 yr will have CHD, MCI, or Stroke within 5 year
Risk

of HTN is regulated by genetic background and environmental factors For every 20/10 mmHg increase BP above 115/75 mmHg, risk of CVD doubles (Chobanian et al, 2003)

 Prevalensi

hipertensi pada penduduk umur 18 tahun ke atas di Indonesia adalah sebesar 31.7 %

Angka

kejadian stroke di Indonesia adalah 8.3 per 1000 penduduk

JAMA. 1990;263:1795-1801

 The

reduction of BP, reduces risk of acute cardiovascular events, progression of atherosclerosis, and end organ injury
mmHg SBP reduction reduces 14 % stroke death and 9 % CVD death (Chobanian et al, 2003) mmHg DBP reduction has benefit for prevention (Cook NR, 1996)

 Atherosclerosis

begins in childhood and evolves over decades (Freedman et al, 1988), affecting > 85% adults > 50yr old (Tuzcu et al, 2001)

Causes

Coronary Artery Disease (CAD) and Peripheral Vascular Disease (PVD)

factors : Dyslipidemia, Hypertension, Impairment of Glucose Control, Age, family history, smoking, obesity, and systemic inflammation

Risk

 High

HDL level reduce the risk of developing CAD (Toth, 2001) Patients with familial low HDL have increase risk of premature CAD (Toth, 2003) Patients with familial high HDL are relatively resistant to CAD (Toth, 2004) The more elevated level of HDL, the lower the risk for CAD

 Risk

factors for CAD

Negative : HDL > 60 mg/dl Positive : Cigarette smoking HDL < 40 mg/dl (men), < 50 mg/dl (women) BP > 140 / > 90 (or use of antihypertensive agents) Family history of premature CAD (CAD in male first degree relative < 55 yr; CAD in female first degree relative < 65yr) Age (men >=45 yr; women >=55 yr)

Risk Assessment Tool for Estimating 10-year Risk of Developing Hard Coronary Heart Disease (Myocardial Infarction and Coronary Death) The risk assessment tool below uses recent data from the Framingham Heart Study to estimate 10-year risk for hard coronary heart disease outcomes (myocardial infarction and coronary death). This tool is designed to estimate risk in adults aged 20 and older who do not have heart disease or diabetes. Use the calculator below to estimate 10-year risk. Age: Gender: Total Cholesterol:
190

35

years Female mg/dL Male

HDL Cholesterol:
Smoker: Systolic Blood Pressure:
Calculate 10-Year Risk

46

mg/dL
No Yes Yes mm/Hg No

110

Currently on any medication to treat high blood pressure.

The Metabolic Syndrome

Hyperglycemia

Physical Inactivity Socioeconomic Birth size, Childhood status growth

Diet

Genetic predisposition

Systemic inflammation
Hyperuricemia Change in Adipose hormones Endothelial dysfunction

Abdominal obesity, Ectopic fat deposition

Dyslipidemia Low HDL, high TG

Insulin Resistance

Hypertension

Diabetes
Textbook of Family Medicine, Rakel, 07

CVD

Hypercoagulability Impaired fibrinolysis

 The

incidence of Metabolic Syndrome increases in men and women as a function of age (Ford et al 2002, Alexander et al 2003)

Patients

with Metabolic Syndrome had 3.77 fold increase in risk of CVD mortality compared to patients without it (Lakka et al 2002)

Risk Factor Abdominal obesity Triglycerides HDL

Blood Pressure Fasting Glucose

Defining Level Men : Waist > 90 cm Women : Waist > 80 cm >=150 mg/dl Men : < 40 mg/dl Women : < 50 mg/dl >=130 / >=85 mmHg >=100 mg/dl

Patients who have ANY THREE (3) of five risk factors meet criteria for the metabolic syndrome

clinical syndrome resulting from the inability of the heart to meet metabolic requirements of the body at normal filling measure Patient with CHF should have their CVD risk factors controlled aggressively Target BP for CHF patients <130/<80 mmHg Target BP for CHF patients WITH DM <125/<85 mmHg

 An

illness of children and adolescents with the average age of onset 8-10 yr with pharyngitis, caries dentis (bad oral hygiene), poverty, crowded living conditions, and difference in access to or utilization of medical care

Associated

 Nepal

: High rates of RHD may not relate to increased prevalence of streptococcal infection, but to inadequate antibiotic therapy (proper dosage and duration) of streptococcal pharyngitis. giving penicillin to school children with pharyngitis (prior to confirmation of its etiology), can reduce the attack rate of rheumatic fever by ten folds.

Philippines:

 Patients

with established cardiac complications must be regularly followed-up. requires cooperation and understanding of prognosis by patients and relatives and counseling on the doctors part

This

 Ventricular Septal Defect Atrial Septal Defect

Tetralogy Fallot
Pulmonary Stenosis Patent Ductus Arteriosus Idiopathic Pulmonary Artery Dilatation

Dextrocardia Hipertensi Pulmonal Primum.

Lain-lain

 Only

1% of the children with congenital heart disease are today properly treated in Indonesia.
The

lack of the information and education on the part of the patients Uneven distribution of doctors A shortage of pediatrician A shortage of funding, both privately and publicly Number of cardiac surgery hospital

17.528.000

CARDIOVASCULAR DISEASES

7.586.000

CANCER

2.830.000
HIV/AIDS
TUBER-CULOSIS MALARIA

4.057.000
CHRONIC RESPIRATORY DISEASE

1.125.000
DIABETES

**Resource: WHO and World Bank 2005

WHO Statistics 2007

Age-standardized CVD mortality rate per 100.000 population (2002)

Timor Leste

441 199 318 171

Thailand Vietnam
Singapore Filipina
COUNTRIES

336
274

Malaysia Indonesia China Jepang Srilanka

India

361
291
mortality

106
314

428
140 182 141 188
0 100 200 300 400 500

Australia
United Kingdom

Canada
United States

WHO Statistics 2007

MORTALITY RATE

DISEASE OCCURANCE : TRIAD EPIDEMIOLOGY

HOST : Characteristic : Age, Gender, Behavior, etc

AGENT : Lipid, Glucose, Bacterial, etc

ENVIRONMENT : Family, Occupation, Housing, Sanitation, etc

 Pharmacology

Drugs
Non

Pharmacology (health education/ counseling) on : Diet, Exercise, Smoking Cessation, Drugs compliance

Individual Perceptions

Modifying Factors Age, gender, ethnicity, Personality, Socioeconomics, Knowledge

Likelihood of Action

Perceived benefits Minus perceived Barriers to behavior change

Perceived susceptibility/ Severity of disease

Perceived threat of disease

Likelihood of Behavior change

Health Behavior and Health Education, Glanz et al, 1997

Cues to action : Education, Symptom, illness Media Information

Social Determinants (Culture, Economy, Finance)

Promotion and Prevention

Risk Factors
Modifiable Diet Physical activity Tobacco Alcohol Non-modifiable Age Genetic

Risk Factors Modifiable High lipids High Blood. Pressure. High Blood. Glucose. Obesity Malnourished

CARDIO VASCULAR DISEASEs Occurance

Promotion

Prevention

Surveillance and Early Treatment

A man, 58 years old, sees his family doctor because of chest pain. He had been well until 2 weeks ago, when he noticed tightness in the center of his chest when he was walking uphill.
Remember Risk Factors (Biopsychosocial)
Died 60 of CVD Died ? of DM

58

Due to lots of contributing factors and broadintegrated disease management : Continuing care and monitoring are important to provide good health services for cardiovascular disease Educational approach and family participation are needed for : Patient to cope with the disease Getting patient and familys independence for improving/maintaining health status

 Menanggulangi

kemiskinan dan kelaparan Mencapai pendidikan dasar untuk semua Mendorong kesetaraan gender dan pemberdayaan perempuan Menurunkan angka kematian anak Meningkatkan kesehatan ibu Memerangi HIV/AIDS, malaria, dan penyakit menular lainnya Memastikan kelestarian lingkungan hidup

Riskesdas 2007 Profil Kesehatan Indonesia 2005 www. americanheart.org Toth PP, et al: Cardiovascular Disease. In: Rakel RE, et all (ed): Textbook of Family Medicine, 7th ed. Philadelphia, Saunders Elsevier, 2007:735-805 Branch WT, et al (ed): Cardiology in Primary Care, Intl ed. New York, McGraw-Hill, 2000 Fletcher RH, et al: Clinical Epidemiology the essentials, 2 nd ed. Baltimore,Williams & Wilkins, 1988 Glanz K, et al: Health Behavior and Health Education, 2 nd ed. San Francisco, Jossey-Bass Publishers, 1997 Affandi M. Penyakit Jantung Bawaan: Apa yang harus dilakukan?. Cermin Dunia Kedokteran no 31 A Ibrahim, et all. Rheumatic Heart Disease: How Big is the Problem?. Med J Malaysia vol 50 no 2 June 1995 Balaban DJ: Epidemiology and Prevention of Selected Chronic Illnesses. In: Cassens BJ (ed): Preventive Medicine and Public Health, 2nd ed. Philadelphia, Harwal Publishing,1992:135-138