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Leaning objectives
LECTURE TWO
Preventive cardiology is the branch of medical science which deals with the prevention of cardiovascular problems and their treatment and rehabilitation.
PREVENTION OF CVD
WHO expert committee recommended on the prevention of CVD as follows. A.
Population Strategy. Prevention in the whole populations. Primordial prevention in the whole populations.
B. C.
Population Strategy.
CHD
Approach
1. Dietary Changes.
2. Smoking
3. Blood Pressure
10
4. Physical Activity
11
A. PRIMORDIAL PREVENTION
12
B. i. ii.
13
C. SECONDARY PREVENTION
Prevent recurrence and progression of CHD (Drug trials, coronary surgery, pace makers
14
D. TERTIARY PREVENTION
15
Smoking
Fat
50-70
60-75
20
Sugar
Starch
Protein
500
CHD = ICD-9 410-414, 429.2. Data source: CDC Wonder
Interventions Policy and Environmental Change Behavior Change Risk Factor Detection and Control Emergency Care/Acute Case Management Rehabilitation /Long-Term Care End-OfLife Care
CHD
40 30 20 10 0 SBP: Chol: Smoking: <118 <182 No 125-131 203-220 No 125-131 203-220 Yes >142 >245 Yes
Phase 2 2000
1985 National decline slows for all but white men; Large regional/ethnic disparities emerge; Tertiary care plays a bigger role.
?? Phase Decline continues for all groups; High 3 2000 15 cholesterol now effectively treated; Cigarette smoking drops to low levels; Dietary goals achieved; Obesity/diabetes epidemic reversed.
1. Cigarettes
* * * tax Enforce sales laws Mount vigorous anti-smoking advertising campaign
2. Food
* * * salt content 5% / year Regulate fast food industry Promote alternate take out foods
3. Obesity/Exercise
* * * * Take up 10% of streets Create walking and bike boulevards Require employers to provide exercise facilities Restore PE in schools
4. Racial/Ethnic/SES Disparities
* * * Develop national health system Invest in economically depressed regions/neighborhoods Provide Scandinavian level social services
SURVEYS
FRAMINGHAM HEART STUDY The Stanford Heart Disease prevention programme in California. The North Kerelia Project in Finland The OSLO study The Multiple Risk Factor Intervention Trial (MRFIT in USA Lipid Research Clinics Study.
3. 4. 5.
6.
1951 one of the best known Prospective study Established the nature of risk factors and their relative importance . Major risk factors were identified. According to this study four main possibilities to intervention in prevention of Reduction of serum cholesterol Cessation of smoking Control of hypertension Promotion of physical activity.
3. 4.
5. 6. 7. 8.
North Keralia is a country in the Eastern part of Finland, where CHD is particularly common. Its 185000 work mostly farming and forestry and live in the countryside A multiple risk factor intervention trial was started in 1972. The aim was reduce the high level of risk factors for CVD(smoking, blood promote the early diagnosis, treatment and rehabilitation of pressure and serum cholesterol).
1. To
2. To
control population was established in a neighbouring country which has similar CV mortality The main strategy was employed community action against risk factors and advice on their avoidance. Follow up 5 years demonstrated a significant reduction in all three major risk factors. By 1979 mortality began to decline by 24 % in men and 51% in women compared with 12% in men and 26% in rest of Finland.
years. Half group randomly allocated to an intervention programme being seen every 4 months to ensure adequate control of risk factors. The other half Control group received medical examination once yearly and no specific advice was given to them. Over 7 years follow up IHD mortality reduced 22% more intervention group.
4.
5.
6.
Study began in 1973 16202 Norwegian men age 40-49 years were screened for CHD risk factors. Of these 1232 healthy normotensive men at risk (total cholesterol 290-379 and smoking) were selected for a 5 year randomized trial. The aim of the study was to determine whether lowering of serum lipids and cessation of smoking would reduce the incidence of first attack of CHD in males aged 40-49 years. The intervention was lowering cholesterol through dietary means (polyunsaturated fat in diet and cessation of smoking. At the end of the incidence of myocardial infarction was lower by 47% in the intervention group than in the control group.
lowering in reducing risk of coronary heart disease (CHD) in 3,806 asymptomatic middle-aged American men with primary hypercholesterolemia (type II hyperlipoproteinemia).
The
treatment group received the bile acid cholestyramine resin and groups followed a moderate cholesterol-lowering diet.
treatment group had an 8.5 % and 12.5% reduction in total resulted in drug treatment of elevated serum cholesterol levels.