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HEART RELATED CONDITIONS OR CARDIOVASCULAR DISEASES Introduction Cardiovascular diseases (CVDs) are a group of disorders of the heart and

blood vessels and they include: Coronary heart disease disease of the blood vessels supplying the heart muscle; Cerebrovascular disease - disease of the blood vessels supplying the brain; Peripheral arterial disease disease of blood vessels supplying the arms and legs; Rheumatic heart disease damage to the heart muscle and heart valves from rheumatic fever, caused by streptococcal bacteria; Congenital heart disease - malformations of heart structure existing at birth; Deep vein thrombosis and pulmonary embolism blood clots in the leg veins, which can dislodge and move to the heart and lungs. Heart attacks and strokes are usually acute events and are mainly caused by a blockage that prevents blood from flowing to the heart or brain. The most common reason for this is a build-up of fatty deposits on the inner walls of the blood vessels that supply the heart or brain. Strokes can also be caused by bleeding from a blood vessel in the brain or from blood clots.

Worldwide Estimates of cardiovascular disease. CVDs are the number one cause of death globally: more people die annually from CVDs than from any other cause. An estimated 17.3 million people died from CVDs in 2008, representing 30% of all global deaths. Of these deaths, an estimated 7.3 million were due to coronary heart disease and 6.2 million were due to stroke. Low- and middle-income countries are disproportionally affected: over 80% of CVD deaths take place in low- and middle-income countries and occur almost equally in men and women. The number of people, who die from CVDs, mainly from heart disease and stroke, will increase to reach 23.3. million by 2030. CVDs are projected to remain the single leading cause of death. Most cardiovascular diseases can be prevented by addressing risk factors such as tobacco use, unhealthy diet and obesity, physical inactivity, high blood pressure, diabetes and raised lipids. 9.4 million deaths each year, or 16.5% of all deaths can be attributed to high blood pressure. This includes 51% of deaths due to strokes and 45% of deaths due to coronary heart disease.

Risk factors for cardiovascular disease The most important behavioural risk factors of heart disease and stroke are unhealthy diet, physical inactivity, tobacco use and harmful use of alcohol. Behavioural risk factors are responsible for about 80% of coronary heart disease and cerebrovascular disease. The effects of unhealthy diet and physical inactivity may show up in individuals as raised blood pressure, raised blood glucose, raised blood lipids, and overweight and obesity. These intermediate risks factors can be measured in primary care facilities and indicate an increased risk of developing a heart attack, stroke, heart failure and other complications. Cessation of tobacco use, reduction of salt in the diet, consuming fruits and vegetables, regular physical activity and avoiding harmful use of alcohol have been shown to reduce the risk of cardiovascular disease. The cardiovascular risk can also be reduced by preventing or treating hypertension, diabetes and raised blood lipids. Policies that create conducive environments for making healthy choices affordable and available are essential for motivating people to adopt and sustain healthy behavior. There are also a number of underlying determinants of CVDs, or "the causes of the causes". These are a reflection of the major forces driving social, economic and cultural change globalization, urbanization, and population ageing. Other determinants of CVDs include poverty, stress and hereditary factors. Symptoms of heart attacks and strokes Often, there are no symptoms of the underlying disease of the blood vessels. A heart attack or stroke may be the first warning of underlying disease. Symptoms of a heart attack include: pain or discomfort in the centre of the chest; pain or discomfort in the arms, the left shoulder, elbows, jaw, or back. In addition the person may experience difficulty in breathing or shortness of breath; feeling sick or vomiting; feeling light-headed or faint; breaking into a cold sweat; and becoming pale. Women are more likely to have shortness of breath, nausea, vomiting, and back or jaw pain. The most common symptom of a stroke is sudden weakness of the face, arm, or leg, most often on one side of the body. Other symptoms include sudden onset of: numbness of the face, arm, or leg, especially on one side of the body; confusion, difficulty speaking or understanding speech;

difficulty seeing with one or both eyes; difficulty walking, dizziness, loss of balance or coordination; severe headache with no known cause; and fainting or unconsciousness. People experiencing these symptoms should seek medical care immediately. rheumatic heart disease Rheumatic heart disease is caused by damage to the heart valves and heart muscle from the inflammation and scarring caused by rheumatic fever. Rheumatic fever is caused by streptococcal bacteria, which usually begins as a sore throat or tonsillitis in children. Rheumatic fever mostly affects children in developing countries, especially where poverty is widespread. Globally, almost 2% of deaths from cardiovascular diseases is related to rheumatic heart disease, while 42% of deaths from cardiovascular diseases is related to ischaemic heart disease, and 34% to cerebrovascular disease Symptoms of rheumatic heart disease Symptoms of rheumatic heart disease include: shortness of breath, fatigue, irregular heart beats, chest pain and fainting. Symptoms of rheumatic fever include: fever, pain and swelling of the joints, nausea, stomach cramps and vomiting. Reduction of the burden of cardiovascular diseases Very cost effective interventions that are feasible to be implemented even in low resource settings have been identified by WHO for prevention and control of cardiovascular diseases. Heart disease and stroke can be prevented through healthy diet, regular physical activity and avoiding tobacco smoke. Individuals can reduce their risk of CVDs by engaging in regular physical activity, avoiding tobacco use and second-hand tobacco smoke, choosing a diet rich in fruit and vegetables and avoiding foods that are high in fat, sugar and salt, and maintaining a healthy body weight and avoiding the harmful use of alcohol. Comprehensive and integrated action is the means to prevent and control CVDs. Comprehensive action requires combining approaches that seek to reduce the risks throughout the entire population with strategies that target individuals at high risk or with established disease.

Examples of population-wide interventions that can be implemented to reduce CVDs include: comprehensive tobacco control policies, taxation to reduce the intake of foods that are high in fat, sugar and salt, building walking and cycle paths to increase physical activity, providing healthy school meals to children. Integrated approaches focus on the main common risk factors for a range of chronic diseases such as CVD, diabetes and cancer: unhealthy diet, physically inactivity and tobacco use. There are several intervention options available. Some of these interventions can be implemented even by non-physician health workers in close- to- client facilities. They are very cost effective and high impact interventions and have been prioritized by WHO. For example: People at high risk can be identified early in primary care, using simple tools such as specific risk prediction charts. If people are identified early, inexpensive treatment is available to prevent many heart attacks and strokes. Survivors of a heart attack or stroke are at high risk of recurrences and at high risk of dying from them. The risk of a recurrence or death can be substantially lowered with a combination of drugs statins to lower cholesterol, drugs to lower blood pressure, and aspirin. In addition surgical operations are sometimes required to treat CVDs. They include coronary artery bypass, balloon angioplasty (where a small balloon-like device is threaded through an artery to open the blockage), valve repair and replacement, heart transplantation, and artificial heart operations. Medical devices are required to treat some CVDs. Such devices include pacemakers, prosthetic valves, and patches for closing holes in the heart. There is a need for increased government investment in prevention and early detection through national programmes aimed at prevention and control of noncommunicable diseases including CVDs. References (1) Global status report on noncommunicable disaeses 2010. Geneva, World Health Organization, 2011. (2) Global atlas on cardiovascular disease prevention and control. Geneva, World Health Organization, 2011. (3) Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLoS Med, 2006, 3(11):e442.

(4) Lim SS, Vos T, Flaxman AD, Danaei G, Shibuya K, Adair-Rohani H et al. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet, 2012, 380(9859):22242260. (5) The global burden of disease: 2004 update. Geneva, World Health Organization, 2008.

ALCOHOLISM AND COMPLICATION Introduction Alcoholism is common, serious, and expensive. Physicians encounter alcohol-related cirrhosis, cardiomyopathy, pancreatitis, and gastrointestinal bleeding, as well as intoxication and alcohol addiction, on a daily basis. Alcoholism is also associated with many cancers. Wernicke encephalopathy and Korsakoff psychosis are also important causes of chronic disability as well as dementia. Fetal alcohol syndrome is a leading cause of mental retardation. In addition, accidents (especially automobile), depression, dementia, suicide, and homicide are important consequences of alcoholism. United States National Longitudinal Alcohol Epidemiologic Study Alcoholism is prevalent in 20% of adult hospital inpatients. One in 6 patients in communitybased primary care practices had problem drinking. The following apply to the US adult population: Current drinkers - 44% Former drinkers - 22% Lifetime abstainers - 34% Abuse and dependency in the past year - 7.5-9.5% Lifetime prevalence - 13.5-23.5% Alcoholism is slightly more common in lower income and less educated groups. Vaillant studied the natural history of alcoholism and the differences between college-educated and inner-city alcoholic persons. He followed 2 cohorts (over 400 patients) of alcoholic patients over many years (Vaillant GE, 1996) According to Vaillant's research, inner-city men began problem drinking approximately 10 years earlier than college graduates (age 25-30 y vs age 40-45 y). Inner-city men were more likely to be abstinent from alcohol consumption than college graduates (30% vs 10%) but more likely to die from drinking (30% vs 15%). A large percentage of college graduates alternated between controlled drinking and alcohol abuse for many years. Returning to controlled drinking from alcohol abuse is uncommon, no more than 10%; however, this figure is likely to be high because it was obtained from self-reported data. Mortality in both groups was related strongly to

smoking. Abstinence for less than 5-6 years did not predict continued abstinence (41% of men abstinent for 2 y relapsed). The National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) study suggests the transition from use to dependence was highest for nicotine users, followed by cocaine, alcohol, and cannabis users (Lopez-Quintero C, et al, 2011). An increased risk of transition to dependence among minorities and those with psychiatric or dependence comorbidity highlights the importance of promoting outreach and treatment of these populations. Binge drinking statistics from the CDC estimate more than 38 million US adults binge drink an average of 4 times a month and the most drinks they consume on average is 8. The report found that binge drinking is more common among households with incomes $75,000, but the largest number of drinks consumed per occasion is highest among households with incomes of <$25,000. INTERNATIONAL The World Health Organization examined mental disorders in primary care offices and found that alcohol dependence or harmful use was present in 6% of patients. In Britain, 1 in 3 patients in community-based primary care practices had at-risk drinking behavior. Alcoholism is more common in France than it is in Italy, despite virtually identical per capita alcohol consumption. Mortality/Morbidity Alcohol use is the third leading cause of preventable death in the United States (after smoking and obesity). Annually, 85,000 deaths are attributable to alcohol at a cost of $185 billion (Mokdad AH et al,. 2004) Almost half of these deaths are attributable to alcohol-related injury. Four percent of the global burden of disease is attributable to alcohol. This figure rises to 7% in North America, Europe, Japan, and Australia and to 12% in Eastern Europe and Central Asia. Worldwide, alcohol is responsible for a percentage of a number of conditions, as follows: Cirrhosis - 32% Motor vehicle accidents - 20% Mouth and oropharyngeal cancers - 19% Esophageal cancer - 29% Liver cancer - 25% Breast cancer - 7% Homicide - 24%

Suicide - 11% Hemorrhagic stroke - 10% An analysis in the United Kingdom in 2010 found that overall, alcohol was found to be the most harmful drug to the person consuming and to others. However, this study does not mean that substances other than alcohol have no harmful consequences; heroin, cocaine, and methamphetamine were found to be the most harmful drugs to individuals themselves. In addition, this study did not address the issue of polydrug abuse, which is a common phenomenon in individuals abusing substances. The combination of alcohol and other substances can lead to serious adverse effects, and such combinations were not explored in this study (Nutt DJ et al,. 2010) Below are the statistically significant relative risks from a study by the American Cancer Society for men and women who consume 4 or more drinks daily. A drink is defined as one 12-oz beer, one 4- to 5-oz glass of wine, or one mixed drink containing 1.5 oz of spirits (80 proof). The relative risk for the noted maladies with consumption of 4 or more drinks daily is as follows: Cirrhosis - For men, 7.5; for women, 4.8 Injuries - For men, 1.3 Ear, nose, and throat cancer; esophagus cancer; liver cancer - For men, 2.8; for women, 3 Moderate alcohol consumption (1-2 drinks/d) reduces the risk of cardiovascular disease in men and women by approximately 30% (Nutt DJ et al,. 2010). The effect of heavy alcohol consumption on the risk of cardiovascular disease varies in different studies. The person's drinking pattern appears to have an effect on cardiovascular disease. Drinking with meals may reduce the risk, while binge drinking increases risk (even in otherwise moderate drinkers). Moderate alcohol consumption appears to increase the risk of breast cancer in women. Total mortality is reduced with moderate alcohol consumption but not with heavy alcohol consumption; the cardiovascular benefit is offset by cirrhosis, cancer, and injuries. The amount of alcohol associated with the lowest mortality appears to be 2 drinks per day in men and 1 drink or fewer per day in women. Moderate alcohol consumption reduces the risk of developing diabetes, but heavy alcohol consumption may increase the risk. The cardiovascular benefit becomes important in men older than 40 years and in women older than 50 years. The risk of hypertension is increased with 3 or more drinks daily.

No benefits are noted in people at low risk for coronary disease (men < 40 y and women < 50 y). Recent data suggest an increase in coronary calcification with moderate alcohol consumption in young adults (Pletcher MJ, 2005). This effect was exacerbated by binge drinking. Of men aged 18-25 years, 60% binge drink. (Binge drinking is defined as 5 alcoholic drinks for men [4 for women] in a row.) Binge drinking significantly increases the risk of injury and contracting sexually transmitted diseases. Women who binge drink at this age are at higher risk of becoming pregnant and potentially harming an unborn child. (Any amount of alcohol consumption during pregnancy is risky.) Cohort data from the Prospective Epidemiological Study of Myocardial Infarction (PRIME) investigated alcohol use patterns on ischemic heart disease in Northern Ireland and France. Regular and moderate alcohol use throughout the week, a typical pattern in middle-aged men in France, was associated with a lower risk of ischemic heart disease, whereas the binge drinking pattern more prevalent in Northern Ireland was associated with a higher risk of ischemic heart disease (Ruidavets JB et al,. 2010) More than three quarters of all foster children in the United States are children of alcohol- or drug-dependent parents. From 60-70% of reported domestic violence incidents involve alcohol. Half of all violent crime is alcohol or drug related. Overall, morbidity and mortality are related strongly to smoking, and people who drink heavily are less likely to quit smoking. Additionally, persons who begin smoking early are more likely to develop problems with alcohol. With regard to pregnancy, fetal alcohol syndrome is the leading known cause ofmental retardation (1 in 1000 births). More than 2000 infants annually are born with this condition in the United States. Alcohol-related birth defects and neurodevelopmental problems are estimated to be 3 times higher. Even small amounts of alcohol consumption may be risky in pregnancy. A 2001 study by Sood et al reported that children aged 6-7 years whose mothers consumed alcohol even in small amounts had more behavioral problems (Sood B et al,. 2001). In a study from 2003, Baer et al showed that moderate alcohol consumption while pregnant resulted in a higher incidence of offspring problem drinking at age 21 years, even after controlling for family history and other environmental factors. All women who are pregnant or planning to become pregnant should avoid alcohol. Race

The 2 largest studies, the US National Comorbidity Survey and the Epidemiologic Catchment Area Survey, both showed a lower prevalence of alcoholism in African Americans than in white Americans. The prevalence was equal or higher in Hispanic Americans compared with white Americans. Studies of Native Americans and Asian Americans are smaller. These studies indicate the prevalence of alcoholism is higher in Native Americans and lower in Asian Americans when compared with white Americans. Sex Alcoholism is at least twice as prevalent in men as it is in women. In the National Comorbidity Survey, it was 2.5 times more prevalent in men than in women. The lifetime prevalence was 20% in men and 8% in women. For alcohol abuse or dependence in the past year, the rates were 10% for men and 4% for women. Women do not metabolize alcohol as efficiently as men. Hazardous drinking (not alcoholism) is greater than 1 drink daily for women and greater than 2 drinks daily for men. Problem drinking in women is much less common than it is in men, and the typical onset of problem drinking in females occurs later than in males. However, progression is more rapid, and females usually enter treatment earlier than males. Women more commonly combine alcohol with prescription drugs of abuse than do males. Women living with substance-abusing men are at high risk. Alcohol problems are less likely to be recognized in women, and women with alcohol problems are less likely to be treated. This may be because women are less likely than men to have job, financial, or legal troubles as a result of drinking. Age The prevalence of alcoholism declines with increasing age. The prevalence in elderly populations is unclear but is probably approximately 3%. A study of the US Medicare population found that alcohol-related hospitalizations were as common as hospitalizations for myocardial infarction. Among older patients with alcoholism, from one third to one half develop alcoholism after age 60 years. This group is harder to recognize. A recent population-based study found that problem drinking (>3 drinks/d) was observed in 9% of older men and in 2% of older women. Alcohol


levels are higher in elderly patients for a given amount of alcohol consumed than in younger patients. Among younger individuals (such as college students), weekly or daily consumption of energy drinks (highly caffeinated beverages) has been strongly associated with alcohol dependence. This population is an important target population for alcohol use disorder prevention (Arria AM et al,. 2010) Reference 1. Arria AM, Caldeira KM, Kasperski SJ, Vincent KB, Griffiths RR, O'Grady KE. Energy Drink Consumption and Increased Risk for Alcohol Dependence. Alcohol Clin Exp Res. Nov 12 2010; 2. CDC Press Release. Binge drinking is bigger problem than previously thought. Centers for Disease Control and Prevention. Lopez-Quintero C, Cobos JP, Hasin DS, et al. Probability and predictors of transition from first use to dependence on nicotine, alcohol, cannabis, and cocaine: Results of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). Drug Alcohol Depend. May 1 2011;115(1-2):120-30. 3. Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual causes of death in the United States, 2000.JAMA. Mar 10 2004;291(10):1238-45. 4. Nutt DJ, King LA, Phillips LD. Drug harms in the UK: a multicriteria decision analysis. Lancet. Nov 6 2010;376(9752):1558-65. 5. Pletcher MJ, Varosy P, Kiefe CI, Lewis CE, Sidney S, Hulley SB. Alcohol consumption, binge drinking, and early coronary calcification: findings from the Coronary Artery Risk Development in Young Adults (CARDIA) Study. Am J Epidemiol. Mar 1 2005;161(5):423-33. 6. Ruidavets JB, Ducimetiere P, Evans A, Montaye M, Haas B, Bingham A. Patterns of alcohol consumption and ischaemic heart disease in culturally divergent countries: the Prospective Epidemiological Study of Myocardial Infarction (PRIME). BMJ. 2010;341:c6077. 7. Sood B, Delaney-Black V, Covington C, et al. Prenatal alcohol exposure and childhood behavior at age 6 to 7 years: I. dose-response effect. Pediatrics. Aug 2001;108(2):E34. 8. Vaillant GE. A long-term follow-up of male alcohol abuse. Arch Gen Psychiatry. Mar 1996;53(3):243-9.