【高血壓英文課件】-心血管疾病的流行病學

EPIDEMIOLOGYOFCARDIOVASCULARDISEASE(CVD)PublicHealthBETTINAPIKO,M.D.,Ph.D.EPIDEMIOLOGYOFCARDIOVASCULAR1

?Cardiovasculardiseasehasthesamemeaningforhealthcaretodayastheepidemicsofcenturieshadformedicineinearliertimes:50%ofthepopulationindevelopedcountriesdieofcardiovasculardisease”(PálKertai)

Someonehasaheartattackeverytwominutes(BritishHeartFoundation)

?Cardiovasculardiseasehast2PublicHealthSignificance-Leadingcauseofmortalityindevelopedcountriesandarisingtendencyindevelopingcountries(diseaseofcivilization)-Amajorimpactonlifeexpectancy-Significantlycontributestomorbidityanddeathratesinthemiddleagedpopulation:potentiallifeyearslost,commoncauseofprematuredeath,laborforce(economiccosts),familylife-Morbidity:nearly30%ofalldisabilitycases-ContributestodeteriorationofthequalityoflifePublicHealthSignificance-Le3【高血壓英文課件】-心血管疾病的流行病學4【高血壓英文課件】-心血管疾病的流行病學5PartsofCardiovascularEpidemiology1.,Descriptiveepidemiology:=Describingdistributionofcardiovasculardiseasebymeansofcertaincharacteristicssuchas:PERSON(i.e.,age,gender,ethnicity)TIMEandPLACE2.,Analyticepidemiology=AnalyzingrelationshipsbetweenCVDandriskfactors(whichelevatetheprobabilityofadiseaseatpopulationlevel),riskmodelandmulticausaldevelopments3.,Experimentalepidemiology/Interventions=Strategiesofcardiovascularprevention(primordial,primary,secondary,tertiary;individualandcommunitylevels)PartsofCardiovascularEpidem6DescriptiveEpidemiologyI.DistributionPatternsintheWorldIntheworld:CVDdeathsaccountforonethirdofalldeaths(25-50%dependingonthelevelofeconomicdevelopment)amongwhich50%:coronarydeathsCVDmadeup16.7millionofglobaldeathsin2002,amongwhich7millionduetocoronaryheartdisease,6millionduetostrokeDistributionoftypesofCVDinglobaldeaths:Globalcardiovasculardeathsin2002:16.7millionamongwhich:coronaryheartdisease7.2million>stroke6.0million>0.9millionhypertensiveheartdisease>0.4millioninflammatoryheartdisease>0.3millionrheumaticheartdisease>1.9millionotherCVDDescriptiveEpidemiologyI.D7DescriptiveEpidemiologyII.AGEQuestion:WhatistherelativeamountofCVDindeathratesindifferentagegroups?-Earlylesionsofbloodvessel,atheroscleroticplaques:around20years-adultlifestylepatternsusuallystartinchildhoodandyouth(smoking,dietaryhabits,sportingbehavior,etc.)-IncreaseinCVDmorbidityandmortality:inage-groupof30-44years-Prematuredeath(<64yearsofage,or25-64years):intheelderlypopulationmoredifficulttointerpretdeathrateduetomultipleillhealthcausesDescriptiveEpidemiologyII.A84,6%11,4%22,5%61,5%32,7%26,9%26,0%14,0%55,8%24,6%14,9%4,7%0%10%20%30%40%50%60%70%80%90%100%1-24yrs25-64yrs>65yrsPROPORTIONOFMORTALITYINDIFFERENTAGE-GROUPS(MEN)

externalotherscancerCVD4,6%11,4%22,5%61,5%32,7%26,9%297,3%17,7%35,0%40,0%31,3%36,5%24,0%8,2%64,7%12,2%18,3%4,8%0%10%20%30%40%50%60%70%80%90%100%1-24yrs25-64yrs>65yrsPROPORTIONOFMORTALITYINDIFFERENTAGE-GROUPS(WOMEN)externalotherscancerCVD7,3%17,7%35,0%40,0%31,3%36,5%210DescriptiveEpidemiologyIII.SEXQuestion:WhatistherelativeamountofCVDindeathratesinwomenandmen?-Widespreadidea:CVDisoftenthoughttobeadiseaseofmiddle-agedmen.-Cardiovascularmortality(fatalcases)aremorecommonamongmen.However,CVDaffectnearlyasmanywomenasmen,albeitatanolderage-Women:specialcase(WHO,2004)a.,Higherriskinwomenthanmen(smoking,hightriglyceridelevels)b.,Higherprevalenceofcertainriskfactorsinwomen(diabetesmellitus,depression)c.,Gender-specificriskfactors(risksforwomenonly)(oralcontraceptives,hormonereplacementtherapy,polycysticovarysyndrome)DescriptiveEpidemiologyIII.11SDR,coronaryheartdiseaseinselectedEuropeancountriesbygender,0-64yrs,per1000000SDR,coronaryheartdiseasein12DescriptiveEpidemiologyIV.ETHNICITYQuestion:WhatistherelativeamountofCVDindeathratesindifferentethnicgroups?-IntheUS:increasedcardiovasculardiseasedeathsinAfrican-AmericanandSouth-AsianpopulationsincomparisonwithWhites-IncreasedstrokeriskinAfrican-American,someHispanicAmerican,Chinese,andJapanesepopulations-Migration:Ni-Hon-SanStudy:JapaneselivinginJapanhadthelowestratesofCHDandcholesterollevels,thoselivinginHawaiihadintermediateratesforboth,thoselivinginSanFranciscohadthehighestratesforbothDescriptiveEpidemiologyIV.E13DescriptiveEpidemiologyV.TIMEandPLACEQuestion:WhatistherelativeamountofCVDindifferentgeographicalplaces?Whatarethetimetrends?InternationalandregionalcharacteristicsofdistributionSDR:StandardizedDeathRateDirectmodeofstandardization,usingtheagedistributionofahypotheticalEuropeanstandardpopulationPrematuredeathratesforcomparisonpurposes(<64yearsofage)DescriptiveEpidemiologyV.14DescriptiveEpidemiologyVI.

WorldTrendsDevelopedcountries:decreasingtendencies(e.g,USA:30%between1988-98,Sweden:42%)-improvementoflifestylefactors,forexample,adecreaseofsmokingandahigherlevelofhealthconsciousnessinmanydevelopedcountries-betterdiagnosticandtherapeuticprocedures(e.g.,bypasssurgeries,hypertensionscreening,pharmacologicaltreatmentofhypertensionandhypercholesterinaemia,accesstohealthcare)Developingcountries:increasingtendencies-increasinglongevity,urbanization,andwesterntypelifestyleDescriptiveEpidemiologyVI.

15DescriptiveEpidemiologyVII.InternationalComparisonsAims:a.,Wherearetherateshigherorlower?b.,Interpretationoftimetrendsc.,InequalitiesincardiovasculardeathDescriptiveEpidemiologyVII.16CardiovasculardeathsinEurope

(SDR,2000)CardiovasculardeathsinEurop17SDR,diseasesofcirculatorysysteminWesternEurope,0-64yrs,per1000000

EU-15average

UnitedKingdom

Switzerland

Spain

Netherlands

Italy

Greece

France

Finland

Denmark

Austria

SDR,diseasesofcirculatorys18SDR,diseasesofcirculatorysysteminEasternEurope,0-64yrs,per1000000

EU-15average(MSsprior1.5.2004)

Slovakia

RussianFederation

Romania

Hungary

Croatia

SDR,diseasesofcirculatorys19SDR,diseasesofcirculatorysysteminHungary,0-64yrs,per1000000

Finland

Hungary

EU-15averageSDR,diseasesofcirculatorys20AnalyticEpidemiologyI.

RoleofRiskFactorsOver300riskfactorshavebeenassociatedwithcoronaryheartdisease,hypertensionandstrokeApprox.75%ofCVDcanbeattributedtoconventionalriskfactorsRiskfactorsofgreatpublichealthsignificance:-highprevalenceinmanypopulations-greatindependentimpactonCVDrisk-theircontrolandtreatmentresultinreducedCVDriskDevelopingcountries:doubleburdenofrisks(problemsofundernutritionandinfections+CVDrisks)AnalyticEpidemiologyI.

Role21AnalyticEpidemiologyII.

ClassificationofRiskFactorsMajormodifiableriskfactorsHighbloodpressureAbnormalbloodlipidsTobaccousePhysicalinactivityObesityUnhealthydietDiabetesmellitusOthermodifiableriskfactorsLowsocioeconomicstatusMentalillhealth(depression)PsychosocialstressHeavyalcoholuseUseofcertainmedicationLipoprotein(a)Non-modifiableriskfactorsAgeHeredityorfamilyhistoryGenderEthnicityorrace”Novel”riskfactorsExcesshomocysteineinbloodInflammatorymarkers(C-reactiveprotein)Abnormalbloodcoagulation(elevatedbloodlevelsoffibrinogen)AnalyticEpidemiologyII.

Cla22AnalyticEpidemiologyIII.Hypertension-Systolicbloodpressure>140Hgmmand/oradiastolicbloodpressure>90Hgmm-Freeofclinicalsymptomsformanyyears(screening)-Inmostcountries,upto30percentofadultssuffering,increasingwithageincivilizedcountries-Positivefamilyhistory-Dietaryhabits(ahighintakeofsalt,processedfood,lowlevelsofwaterhardness,highthyraminecontentoffood,alcoholuse)-Modernlifestyle(increasedsympatheticactivity,psychosocialstress,leadingpositioninjob)AnalyticEpidemiologyIII.Hyp23AnalyticEpidemiologyIV.

RheumaticFeverandRheumaticHeartDiseaseDevelopment:Rheumaticfeverusuallyfollowsanuntreatedbeta-haemolyticstreptococcalthroatinfectioninchildrenAsaconsequence,theheartvalvesarepermanentlydamagedwhichmayprogresstoheartfailureTodaymostlyaffectschildrenindevelopingcountries,linkedtopoverty,inadequacyofhealthcareaccessOccurrence:12millionpeoplecurrentlyaffectedbyrheumaticfeverandRHD,two-thirdsarechildren(5-15years),forexample:approx.1000000inSub-SaharanAfrica,700000inSouth-CentralAsia,176000inChina,150000inNorthAfrica,40000inEasternEurope(!)AnalyticEpidemiologyIV.

Rhe24AnalyticEpidemiologyV.AbnormalBloodLipids-Secholesterol:structureandfunctioningofbloodvessels,atheroscleroticplaques-Alteringfunctionsofcholesterolfractions(LDL:risk,HDL:protection)-Estrogen:tendstoraiseHDL-cholesterolandlowerLDL-cholesterol,protectionforwomeninreproductiveage-Partiallygeneticdeterminationofmetabolism,partiallydependentofnutrition(egg,meats,dairyproducts)AnalyticEpidemiologyV.25CurrentRecommendedLipidLevelsEuropeanguidelinesUSguidelinesTotalcholesterol<5.0mmol/l<240mg/dl(6.2mmol/l)LDL-cholesterol<3.0mmol/l<160mg/dl(3.8mmol/l)HDL-cholesterol>=1.0mmol/l(men)>=1.2mmol/l(women)>=40mg/dl(1mmol/l)Triglycerides(fasting)<1.7mmol/l<200mg/dl(2.3mmol/l)CurrentRecommendedLipidLeve26AnalyticEpidemiologyVI.

TobaccoUse-ThelinkbetweensmokingandCVD(mainlyCHD)wasidentifiedin1940-Greatestrisk:initiation<16years-Passivesmoking:additionalrisk-Womensmokers:areathigherriskofCHDandCVDthanmalesmokers-Severalmechanisms:damagestheendotheliumlining,increasesatheroscleroticplaques,raisesLDLandlowersHDL,promotesarteryspasms,raisesoxigendemandoftheheartmuscle-Nicotineacceleratestheheartrate(RR),andraisesbloodpressureAnalyticEpidemiologyVI.

Tob27AnalyticEpidemiologyVII.PhysicalInactivity-Regularphysicalactivity:protectivefactor-Intensityandduration(150minutes/weekintermediateor60minutes/weekheavy)-Modernization,urbanization,mechanizedtransport:sedentarylifestyle(60%ofglobalpopulation)-RaisesCVDriskandalsothedevelopmentofotherriskfactors(glucosemetabolism,diabetesmellitus,bloodcoagulation,obesity,highbloodpressure,worseninglipidprofile)-Physicalactivity:helpsreducestress,anxietyanddepressionAnalyticEpidemiologyVII.28AnalyticEpidemiologyVIII.

Obesity,DiabetesMellitus,UnhealthyDiet

-BodyMassIndex:>25:overweight,>30:obesity-Amodern”epidemic”:Morethan60%ofadultsintheUSareoverweightorobese,inChina:70millionoverweightpeople-ElevatestheriskofbothCVDanddiabetesmellitus-Diabetesmellitus:damagesbothperipheralandcoronarybloodvessels-Unhealthydiet:lowfruitandvegetable,fibercontent,andhighsaturatedfatintake,refinedsugarAnalyticEpidemiologyVIII.

O29AnalyticEpidemiologyIX.Psychologicalandsocialfactors-Psychologicalfactors(TypeAbehavior,hostility)-DepressionandCVD:bidirectionallinka.,depressionmayincreasetheriskofCVDandworsenrecoveryprocessb.,CVDmayinducedepression-Lowsocioeconomicstatus(SES):a.,indevelopedcountries:lesseducatedandlowerSESgroups(accumulationofriskfactors)b.,indevelopingcountries:moreeducatedandhigherSESgroups(westernlifestyle)AnalyticEpidemiologyIX.Psy30CardiovascularPreventionI.Primordial:Social,legalandother(oftennonmedical)activitieswhichmayleadtoaloweringofriskfactors(e.g.,socioeconomicdevelopment,smoke-freerestaurants)Primary:ControllingriskfactorscontributingtoCVD(healtheducationprograms,anti-smokingcampaign,sportsprograms,nutritioncounselling,regularcheckofbloodpressureandcertainbloodparameters,e.g.,cholesterol,bloodlipids,glucose)Secondary:Screeningandtreatmentofsymptomaticpatients,setuppersonalriskprofileTertiary:Cardiovascularrehabilitation,preventionofrecurrenceofCVD(newheartattack:5-7timeshigherriskamongCVDpatients)CardiovascularPreventionI.Pr31CardiovascularPreventionII.Theindividualapproach(detectingthoseatgreatestrisk):lifestyleguidelines(e.g.,smokingcessation)Thepopulation-wideapproach:(thewholepopulation,westernlifestyle)Exampleforcommunity-wideCVpreventionprograms:-FraminghamHeartStudy(1948-)FraminghamRiskScoring-North-KareliaProject(1972-)Finland-StanfordProjects(1972-75,1980-86)USA-MinnesotaCardiovascularHealthProgram(1980-88)USA-MultipleRiskfactorInterventionTrial(1972-79)USACardiovascularPreventionII.T32ReviewQuestions(DevelopedbytheSupercourseteam)WhatmaybethereasonsforthedecliningCVDincidencerates?Atthesametimethattherehasbeenanepidemicofobesity,theratesofCVDhasmarkedlydeclined.Whyhasn’tCVDgoupinthepopulationasobesityhasskyrocketed?DefinethestepstopreventCHDReviewQuestions(Developedby33EPIDEMIOLOGYOFCARDIOVASCULARDISEASE(CVD)PublicHealthBETTINAPIKO,M.D.,Ph.D.EPIDEMIOLOGYOFCARDIOVASCULAR34

?Cardiovasculardiseasehasthesamemeaningforhealthcaretodayastheepidemicsofcenturieshadformedicineinearliertimes:50%ofthepopulationindevelopedcountriesdieofcardiovasculardisease”(PálKertai)

Someonehasaheartattackeverytwominutes(BritishHeartFoundation)

?Cardiovasculardiseasehast35PublicHealthSignificance-Leadingcauseofmortalityindevelopedcountriesandarisingtendencyindevelopingcountries(diseaseofcivilization)-Amajorimpactonlifeexpectancy-Significantlycontributestomorbidityanddeathratesinthemiddleagedpopulation:potentiallifeyearslost,commoncauseofprematuredeath,laborforce(economiccosts),familylife-Morbidity:nearly30%ofalldisabilitycases-ContributestodeteriorationofthequalityoflifePublicHealthSignificance-Le36【高血壓英文課件】-心血管疾病的流行病學37【高血壓英文課件】-心血管疾病的流行病學38PartsofCardiovascularEpidemiology1.,Descriptiveepidemiology:=Describingdistributionofcardiovasculardiseasebymeansofcertaincharacteristicssuchas:PERSON(i.e.,age,gender,ethnicity)TIMEandPLACE2.,Analyticepidemiology=AnalyzingrelationshipsbetweenCVDandriskfactors(whichelevatetheprobabilityofadiseaseatpopulationlevel),riskmodelandmulticausaldevelopments3.,Experimentalepidemiology/Interventions=Strategiesofcardiovascularprevention(primordial,primary,secondary,tertiary;individualandcommunitylevels)PartsofCardiovascularEpidem39DescriptiveEpidemiologyI.DistributionPatternsintheWorldIntheworld:CVDdeathsaccountforonethirdofalldeaths(25-50%dependingonthelevelofeconomicdevelopment)amongwhich50%:coronarydeathsCVDmadeup16.7millionofglobaldeathsin2002,amongwhich7millionduetocoronaryheartdisease,6millionduetostrokeDistributionoftypesofCVDinglobaldeaths:Globalcardiovasculardeathsin2002:16.7millionamongwhich:coronaryheartdisease7.2million>stroke6.0million>0.9millionhypertensiveheartdisease>0.4millioninflammatoryheartdisease>0.3millionrheumaticheartdisease>1.9millionotherCVDDescriptiveEpidemiologyI.D40DescriptiveEpidemiologyII.AGEQuestion:WhatistherelativeamountofCVDindeathratesindifferentagegroups?-Earlylesionsofbloodvessel,atheroscleroticplaques:around20years-adultlifestylepatternsusuallystartinchildhoodandyouth(smoking,dietaryhabits,sportingbehavior,etc.)-IncreaseinCVDmorbidityandmortality:inage-groupof30-44years-Prematuredeath(<64yearsofage,or25-64years):intheelderlypopulationmoredifficulttointerpretdeathrateduetomultipleillhealthcausesDescriptiveEpidemiologyII.A414,6%11,4%22,5%61,5%32,7%26,9%26,0%14,0%55,8%24,6%14,9%4,7%0%10%20%30%40%50%60%70%80%90%100%1-24yrs25-64yrs>65yrsPROPORTIONOFMORTALITYINDIFFERENTAGE-GROUPS(MEN)

externalotherscancerCVD4,6%11,4%22,5%61,5%32,7%26,9%2427,3%17,7%35,0%40,0%31,3%36,5%24,0%8,2%64,7%12,2%18,3%4,8%0%10%20%30%40%50%60%70%80%90%100%1-24yrs25-64yrs>65yrsPROPORTIONOFMORTALITYINDIFFERENTAGE-GROUPS(WOMEN)externalotherscancerCVD7,3%17,7%35,0%40,0%31,3%36,5%243DescriptiveEpidemiologyIII.SEXQuestion:WhatistherelativeamountofCVDindeathratesinwomenandmen?-Widespreadidea:CVDisoftenthoughttobeadiseaseofmiddle-agedmen.-Cardiovascularmortality(fatalcases)aremorecommonamongmen.However,CVDaffectnearlyasmanywomenasmen,albeitatanolderage-Women:specialcase(WHO,2004)a.,Higherriskinwomenthanmen(smoking,hightriglyceridelevels)b.,Higherprevalenceofcertainriskfactorsinwomen(diabetesmellitus,depression)c.,Gender-specificriskfactors(risksforwomenonly)(oralcontraceptives,hormonereplacementtherapy,polycysticovarysyndrome)DescriptiveEpidemiologyIII.44SDR,coronaryheartdiseaseinselectedEuropeancountriesbygender,0-64yrs,per1000000SDR,coronaryheartdiseasein45DescriptiveEpidemiologyIV.ETHNICITYQuestion:WhatistherelativeamountofCVDindeathratesindifferentethnicgroups?-IntheUS:increasedcardiovasculardiseasedeathsinAfrican-AmericanandSouth-AsianpopulationsincomparisonwithWhites-IncreasedstrokeriskinAfrican-American,someHispanicAmerican,Chinese,andJapanesepopulations-Migration:Ni-Hon-SanStudy:JapaneselivinginJapanhadthelowestratesofCHDandcholesterollevels,thoselivinginHawaiihadintermediateratesforboth,thoselivinginSanFranciscohadthehighestratesforbothDescriptiveEpidemiologyIV.E46DescriptiveEpidemiologyV.TIMEandPLACEQuestion:WhatistherelativeamountofCVDindifferentgeographicalplaces?Whatarethetimetrends?InternationalandregionalcharacteristicsofdistributionSDR:StandardizedDeathRateDirectmodeofstandardization,usingtheagedistributionofahypotheticalEuropeanstandardpopulationPrematuredeathratesforcomparisonpurposes(<64yearsofage)DescriptiveEpidemiologyV.47DescriptiveEpidemiologyVI.

WorldTrendsDevelopedcountries:decreasingtendencies(e.g,USA:30%between1988-98,Sweden:42%)-improvementoflifestylefactors,forexample,adecreaseofsmokingandahigherlevelofhealthconsciousnessinmanydevelopedcountries-betterdiagnosticandtherapeuticprocedures(e.g.,bypasssurgeries,hypertensionscreening,pharmacologicaltreatmentofhypertensionandhypercholesterinaemia,accesstohealthcare)Developingcountries:increasingtendencies-increasinglongevity,urbanization,andwesterntypelifestyleDescriptiveEpidemiologyVI.

48DescriptiveEpidemiologyVII.InternationalComparisonsAims:a.,Wherearetherateshigherorlower?b.,Interpretationoftimetrendsc.,InequalitiesincardiovasculardeathDescriptiveEpidemiologyVII.49CardiovasculardeathsinEurope

(SDR,2000)CardiovasculardeathsinEurop50SDR,diseasesofcirculatorysysteminWesternEurope,0-64yrs,per1000000

EU-15average

UnitedKingdom

Switzerland

Spain

Netherlands

Italy

Greece

France

Finland

Denmark

Austria

SDR,diseasesofcirculatorys51SDR,diseasesofcirculatorysysteminEasternEurope,0-64yrs,per1000000

EU-15average(MSsprior1.5.2004)

Slovakia

RussianFederation

Romania

Hungary

Croatia

SDR,diseasesofcirculatorys52SDR,diseasesofcirculatorysysteminHungary,0-64yrs,per1000000

Finland

Hungary

EU-15averageSDR,diseasesofcirculatorys53AnalyticEpidemiologyI.

RoleofRiskFactorsOver300riskfactorshavebeenassociatedwithcoronaryheartdisease,hypertensionandstrokeApprox.75%ofCVDcanbeattributedtoconventionalriskfactorsRiskfactorsofgreatpublichealthsignificance:-highprevalenceinmanypopulations-greatindependentimpactonCVDrisk-theircontrolandtreatmentresultinreducedCVDriskDevelopingcountries:doubleburdenofrisks(problemsofundernutritionandinfections+CVDrisks)AnalyticEpidemiologyI.

Role54AnalyticEpidemiologyII.

ClassificationofRiskFactorsMajormodifiableriskfactorsHighbloodpressureAbnormalbloodlipidsTobaccousePhysicalinactivityObesityUnhealthydietDiabetesmellitusOthermodifiableriskfactorsLowsocioeconomicstatusMentalillhealth(depression)PsychosocialstressHeavyalcoholuseUseofcertainmedicationLipoprotein(a)Non-modifiableriskfactorsAgeHeredityorfamilyhistoryGenderEthnicityorrace”Novel”riskfactorsExcesshomocysteineinbloodInflammatorymarkers(C-reactiveprotein)Abnormalbloodcoagulation(elevatedbloodlevelsoffibrinogen)AnalyticEpidemiologyII.

Cla55AnalyticEpidemiologyIII.Hypertension-Systolicbloodpressure>140Hgmmand/oradiastolicbloodpressure>90Hgmm-Freeofclinicalsymptomsformanyyears(screening)-Inmostcountries,upto30percentofadultssuffering,increasingwithageincivilizedcountries-Positivefamilyhistory-Dietaryhabits(ahighintakeofsalt,processedfood,lowlevelsofwaterhardness,highthyraminecontentoffood,alcoholuse)-Modernlifestyle(increasedsympatheticactivity,psychosocialstress,leadingpositioninjob)AnalyticEpidemiologyIII.Hyp56AnalyticEpidemiologyIV.

RheumaticFeverandRheumaticHeartDiseaseDevelopment:Rheumaticfeverusuallyfollowsanuntreatedbeta-haemolyticstreptococcalthroatinfectioninchildrenAsaconsequence,theheartvalvesarepermanentlydamagedwhichmayprogresstoheartfailureTodaymostlyaffectschildrenindevelopingcountries,linkedtopoverty,inadequacyofhealthcareaccessOccurrence:12millionpeoplecurrentlyaffectedbyrheumaticfeverandRHD,two-thirdsarechildren(5-15years),forexample:approx.1000000inSub-SaharanAfrica,700000inSouth-CentralAsia,176000inChina,150000inNorthAfrica,40000inEasternEurope(!)AnalyticEpidemiologyIV.

Rhe57AnalyticEpidemiologyV.AbnormalBloodLipids-Secholesterol:structureandfunctioningofbloodvessels,atheroscleroticplaques-Alteringfunctionsofcholesterolfractions(LDL:risk,HDL:protection)-Estrogen:tendstoraiseHDL-cholesterolandlowerLDL-cholesterol,protectionforwomeninreproductiveage-Partiallygeneticdeterminationofmetabolism,partiallydependentofnutrition(egg,meats,dairyproducts)AnalyticEpidemiologyV.58CurrentRecommendedLipidLevelsEuropeanguidelinesUSguidelinesTotalcholesterol<5.0mmol/l<240mg/dl(6.2mmol/l)LDL-cholesterol<3.0mmol/l<160mg/dl(3.8mmol/l)HDL-cholesterol>=1.0mmol/l(men)>=1.2mmol/l(women)>=40mg/dl(1mmol/l)Triglycerides(fasting)<1.7mmol/l<200mg/dl(2.3mmol/l)CurrentRecommendedLipidLeve59AnalyticEpidemiologyVI.

TobaccoUse-ThelinkbetweensmokingandCVD(mainlyCHD)wasidentifiedin1940-Greatestrisk:initiation<16years-Passivesmoking:additionalrisk-Womensmokers:areathigherriskofCHDandCVDthanmalesmokers-Severalmechanisms:damagestheendotheliumlining,increasesatheroscleroticplaques,raisesLDLandlowersHDL,promotesarteryspasms,raisesoxigendemandoftheheartmuscle-Nicotineacceleratestheheartrate(RR),andraisesbloodpressureAnalyticEpidemiologyVI.

Tob60AnalyticEpidemiologyVII.PhysicalInactivity-Regularphysicalactivity:protectivefactor-Intensityandduration(150minutes/weekintermediateor60minutes/weekheavy)-Modernization,urbanization,mechanizedtransport:sedentarylifestyle(60%ofglobalpopulation)-RaisesCVDriskandalsothedevelopmentofotherriskfactors(glucosemetabolism,diabetes