Continuum of CV Disease Prevention A Manifesto Thomas G Allison, PhD, MPH, FACC Mayo Clinic Rochester, MN USA VNHA – Da Nang October, 2014 ©2012 MFMER | slide-1 No Disclosures The Broad Plain of CV Prevention Coronary heart disease Stroke Heart failure Atrial fibrillation Peripheral artery disease Diabetes Erectile dysfunction ©2012 MFMER | slide-3 Continuum of Personal lifestyle Cardiovascular Disease Public Health Community Programs Prevention Polypill Primary Prevention Clinic-Based Acute Treatment Hospital-Based Cardiac Rehabilitation Secondary Prevention Clinic-Based Progression of CV Prevention • Primordial – young, healthy individuals $ • Preventing atherosclerotic vascular disease • Primary – high risk patients/subclinical disease • Stopping or reversing disease progression $$ • Preventing clinical events – MI, CVA, SCD • Secondary – after the clinical event • Reducing CV morbidity – AF, HF, CVA $$$ã Delaying death ã Reducing healthcare costs â2012 MFMER | slide-5 Cardiovascular Prevention Works CV disease rates change over time Changes in personal behaviors can change CV disease rates Community interventions can change disease rates Physician interventions change can CV disease rates ©2012 MFMER | slide-6 Age-adjusted US Heart Disease Trends Nemetz et al Arch Intern Med 2008;163:264-270 42% decrease in age-adjusted heart disease death rate since 1967 7447 people with high CV risk No known CVD Randomized to Med diet + EVOO Med diet + nuts Control Followed median 4.8 years PREDIMED Study Estruch R et al N Engl J Med 2013;368:1279-90 ©2012 MFMER | slide-8 Age-standardized mortality from ischaemic heart disease from 1969 to 1992 in men and women aged 35–64 in Finland Vartiainen E et al BMJ 1994;309:23-27 Observed and predicted decline in mortality from ischaemic disease in men aged 35–64 in Finland • Dr Pekka Puska • Decreased dietary fat and cholesterol • Reduced smoking • Reduced sodium intake • Opportunities for physical activity • Benefit from improved cardiac care and secondary prevention Vartiainen E et al BMJ 1994;309:23-27 Living Under the Umbrella of Good Cardiovascular Health Impact of Secondary Prevention Therapies from 4S: Effects on Coronary Events Placebo 28.9% Statin only 18.6% 70% of events 11.2% eliminated with just therapies Statin+ASA Statin+ ASA+BB 8.6% 10 15 20 25 6-Year Coronary Event Rate (%) Kjekshus, J Am J Chron Dis 1995;76:64C-68C 30 35 CHD Trends McGovern et al, Circulation 2001;104:19-24 Jernberg T et al JAMA 2011;305:1677-1684 Jernberg T et al JAMA 2011;305:1677-1684 43% reduction in mortality from 1996-1997 to 2006-2007 Jernberg T et al JAMA 2011;305:1677-1684 ©2012 MFMER | slide-27 ©2012 MFMER | slide-28 ©2012 MFMER | slide-29 ©2012 MFMER | slide-30 CV disease lends itself to prevention Fatty Streaks in Aorta of Male age 19 Advanced Lesion with Large Lipid Core Plaque Rupture with Torn Cap Advanced Lesion Occluded with Thrombus Value of History • Those who cannot remember the past are condemned to repeat it • George Santayana (1863-1952) • Without strong preventive efforts, low- and middle-income countries will suffer a devastating epidemic of CV disease • Already happening • History is bunk • Henry Ford (1863-1947) • Prevention works We can much to attenuate the CV disease epidemic