EPIDEMIOLOGY,

PREVENTION & PROMOTION

FOR CARDIOVASCULAR
DISEASE (CVD)
Community Medicine Department
Faculty of Medicine University of Indonesia

Setyawati Budiningsih, Retno Asti Werdhani

Feb 16. 2009

DESCRIPTIVE ANALYTIC
EPIDEMIOLOGY EPIDEMIOLOGY

Incidence Risk Factors

Prevalence

Triad Epidemiology Diagnostic Tools

Host – Agent - Environment

Holistic Diagnosis
(BIOPSYCHOSOSIAL)

CLINICAL EPIDEMIOLOGY
(Prognostic Study, Clinical Therapy, Prognosis
Trial, Meta Analysis)
 GLOBAL DEATHS BY CAUSE, ALL AGES
2005
17.528.000

CARDIO-
VASCULAR
DISEASES

7.586.000

CANCER 4.057.000
2.830.000
1.607.000 1.125.000
CHRONIC
HIV/AIDS 883.000 RESPIRATORY
TUBER-CULOSIS DISEASE
MALARIA DIABETES

**Resource: WHO and World Bank 2005

WHO Statistics 2007
 Age-standardized CVD mortality rate per 100.000
population (2002)

Timor Leste 441

Thailand 199
Vietnam 318
Singapore 171
Filipina 336
Malaysia 274
COUNTRIES

Indonesia 361
China 291 mortality
Jepang 106
Srilanka 314
India 428
Australia 140
United Kingdom 182
Canada 141
United States 188
0 100 200 300 400 500
MORTALITY RATE
WHO Statistics 2007
 Trend Pola Penyakit Penyebab Utama Kematian
dalam kurun waktu 10 Tahun di Indonesia
SKRT 1992, 1995, 2001

Persentase
35

30

25

20

15

10

0
Inf & Par Sirkulasi Pernapasan Sal. Cerna Neoplasma Kecelakaan Perinatal
1992 1995 2001

Laporan SKRT 2001: Studi Morbiditas & Disabilitas, Litbangkes 2002

 RISK FACTORS OF CVD
• Predispose factors :
– Age, Gender, Family history, Behavior,
Sanitation, etc

• Clinical Risk factors :

– Obesity/Malnourished, Hypertension
Dyslipidemia, Impairment of Glucose
Control,, and Systemic Inflammation, etc
 COMMON CVD
IN PRIMARY CARE

• Hypertension
• Atherosclerotic Coronary Heart Disease
and Peripheral Vascular Disease
• Congestive Heart Failure
• Congenital Heart Disease
• Valvular Health Disease
• Cardiac Arrhythmias
 HYPERTENSION
• 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)
JAMA. 1990;263:1795-1801
 HYPERTENSION
• The reduction of BP, reduces risk of
acute cardiovascular events, progression
of atherosclerosis, and end organ injury

• 5 mmHg SBP reduction reduces 14 %

stroke death and 9 % CVD death
(Chobanian et al, 2003)

• 2 mmHg DBP reduction has benefit for

prevention (Cook NR, 1996)
 ATHEROSCLEROSIS
• 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)

• Risk factors : Dyslipidemia, Hypertension,

Impairment of Glucose Control, Age, family
history, smoking, obesity, and systemic
inflammation
 Dyslipidemia  CAD
• 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
 Dyslipidemia  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)
 METABOLIC SYNDROME

• The metabolic syndrome is a

constellation of CVD risk factors and is
associated with heightened risk of CV
morbidity and mortality
• The metabolic syndrome is an insulin
resistant state associated with visceral
adiposity, hypertension, hyperglycemia,
dyslipidemia, and a pro-inflammatory
and pro-oxidative state
 Genetic
The Diet
predisposition
Physical
Metabolic Inactivity Socioeconomic Birth size,
Syndrome status
Childhood
growth
Systemic
inflammation
Hyperglycemia
Abdominal obesity, Hyperuricemia
Ectopic fat deposition
Dyslipidemia Change in
Low HDL, high TG Insulin Adipose
Resistance hormones

Endothelial
Hypertension dysfunction

Hypercoagulability
Diabetes
Impaired fibrinolysis
CVD

Textbook of FM, Rakel, 07

 METABOLIC SYNDROME
Risk Factor Defining Level
Abdominal obesity Men : Waist > 90 cm
Women : Waist > 80 cm
Triglycerides >=150 mg/dl
HDL Men : < 40 mg/dl
Women : < 50 mg/dl
Blood Pressure >=130 / >=85 mmHg
Fasting Glucose >=100 mg/dl

• Patients who have ANY THREE (3) of five risk factors

meet criteria for the metabolic syndrome
 METABOLIC SYNDROME
• 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 Assessment Tool for Estimating 10-year Risk of Developing Hard
CHD (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: 32 years
Gender: Female Male
Total Cholesterol: 190 mg/dL
HDL Cholesterol: 46 mg/dL
Smoker: No Yes
Systolic Blood Pressure: 110 mm/Hg
Currently on any medication to treat high blood pressure. No Yes
Calculate 10-Year Risk
Risk score results:

Age: 32
Gender: female
Total Cholesterol: 190 mg/dL
HDL Cholesterol: 46 mg/dL
Smoker: No
Systolic Blood Pressure: 110 mm/Hg
On medication for HBP: No

Risk Score* Less than 1%

Risk Assessment Tool for Estimating 10-year Risk of Developing Hard
CHD (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: 58 years
Gender: Female Male
Total Cholesterol: 280 mg/dL
HDL Cholesterol: 45 mg/dL
Smoker: No Yes
Systolic Blood Pressure: 130 mm/Hg
Currently on any medication to treat high blood pressure. No Yes
Calculate 10-Year Risk
Risk score results:

Age: 58
Gender: male
Total Cholesterol: 280 mg/dL
HDL Cholesterol: 45 mg/dL
Smoker: Yes
Systolic Blood Pressure: 130 mm/Hg
On medication for HBP: Yes

Risk Score* 27%

 FRAMINGHAM CALCULATOR
Can be downloaded from :
• www.google.com
 keywords : Framingham calculator

• http://hp2010.nhlbihin.net/atpiii/calcula
tor.asp?usertype=prof

• http://www.intmed.mcw.edu/clincalc/hea
rtrisk.html
 CIGARETTE SMOKING
• Smoking raises risk of atherosclerotic
disease and potentiates 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.
 CONGESTIVE HEART FAILURE
• A 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
• Patients with history of palpitation  evaluate
for Tachycardia  risk factor for
cardiomyopathy and CHF
 ACUTE RHEUMATIC FEVER
• An illness of children and adolescents
with the average age of onset 8-10 yr

• Associated with pharyngitis, caries

dentis (bad oral hygiene), poverty,
crowded living conditions, and
difference in access to or utilization of
medical care
 Rheumatic Heart Disease
• Nepal : High rates of ARF and RHD may not
relate to increased prevalence of
streptococcal infection, but to inadequate
antibiotic therapy (proper dosage and
duration) of streptococcal pharyngitis.

• Philippines: giving penicillin to school children

with pharyngitis (prior to confirmation of its
etiology), the attack rate of rheumatic fever
can be reduced by ten folds.
 Rheumatic Heart Disease
• Patients with established cardiac
complications must be regularly
followed-up.

• This requires cooperation and

understanding of prognosis by patients
and relatives and counseling on the
doctors‘ part
 The 10th prevalent Congenital Heart
Diseases, Pediatric Dept , FKUI - RSCM

• Ventricular Septal Defect

• Atrial Septal Defect
• Tetralogy Fallot
• Pulmonary Stenosis
• Patent Ductus Arteriosus
• Idiopathic Pulmonary Artery Dilatation
• Dextrocardia
• Hipertensi Pulmonal Primum.
• Lain-lain
 ETIOLOGY of CHD
(Congenital Heart Disease)

• Genetic Factor :
– Abnormal chromosom 5 %
– Single genetic mutation 3 %
• Environmental Factor :
– Rubella 1 %
– Others 1 %

• Genetic Factor + Environment 90 %

 Congenital Heart Disease
• CHD risk reduced by prevention in
prenatal period

• Rubella before adolescence in girls could

result in long active immunity .

• Rubella viraemia post infection could

stay several weeks.
 Congenital Heart Disease
• 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, and
– Uneven distribution of doctors
– a shortage of pediatrician
– a shortage of funding, both privately and
publicly
– Number of cardiac surgery hospital
 DISEASE OCCURANCE :
TRIAD EPIDEMIOLOGY
HOST :
Characteristic : AGENT :
Age, Gender, Lipid, Glucose,
Behavior, Bacterial, etc
etc

ENVIRONMENT :
Family, Occupation,
Housing,
Sanitation, etc
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.
Questions : Is he sick ? What is the appropriate diagnosis ?
Causal of the illness ? How is the treatment and prognosis ?
Remember Risk Factors (Biopsychosocial)
Died 60 Died ?
of CVD of DM

58
 THERAPY
• Pharmacology
– Drugs

• Non Pharmacology
(health education/ counseling) on :
– Diet, Exercise, Smoking Cessation, drug’s
compliance
 Health Belief Model
Individual Likelihood
Modifying Factors
Perceptions of Action

Age, gender, ethnicity, Perceived benefits

Personality, Minus perceived
Socioeconomics, Barriers to behavior
Knowledge change

Perceived
susceptibility/ Perceived threat Likelihood of
Severity of disease of disease Behavior change

Cues to action :
Health Behavior and Education,
Health Education, Symptom, illness
Glanz et al, 1997 Media Information
 BEHAVIORAL INTERVENTION
• Patient’s health education

• Diet, Exercise, Lifestyle Modification, Alcohol

reduction, Smoking Cessation, Drug’s compliance

• 20% reduction of cardiac and total mortality in

post-MCI patients

• Without proper patient education component, the

medical management plan is incomplete and is
unlikely to be complied
BEHAVIORAL INTERVENTION

• Changes in patient’s knowledge does not

guarantee changes in patient’s behavior

• Understanding the ‘stages of change’

• Behavioral changes do not occur rapidly,

may be months or years required

• Stage-specific counseling
 Prochaska’s Model of
Behavior Change
• Precontemplation
– Patient is not even thinking about changing the behavior within the
next 6 months
• Contemplation
– Patient is considering a behavior change within the next 6 months
but not within the next 1 month
• Preparation
– Patient has stated that he or she will change his or her behavior in
the next 1 month
• Action
– Patient has actually implemented the behavior change and
contracting has occurred
• Maintenance
– The behavior change has been in place for at least 6 months and is
being incorporated into patient’s lifestyle
• Relapse
– Not a specific stage, but something that can occur at any time
during the process
Prevention Social Determinants
and control (Culture, Economy, Promotion and
Finance) Prevention
of CVD

Risk Factors
Risk Factors
•Modifiable
• Diet •Modifiable
• High lipids CARDIO -
• Physical activity
• Tobacco
• High Blood. VASCULAR
Pressure.
• Alcohol • High Blood. DISEASE
•Non-modifiable Glucose.
• Age • Obesity
• Genetic • Malnourished

Surveillance and
Promotion Prevention Early Treatment
 EPIDEMIOLOGY :
-Risk Factors
-Diagnostic tools
-Therapy
-Prognosis

IMPLEMENTATION INDIVIDUAL

OF
EPIDEMIOLOGY
4 B’S :
Burden of disease
Belief, Bargain, Barrier

COMMUNITY
 REFERENCES
• 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
• 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
 REFERENCES
• Fletcher RH, et al: Clinical Epidemiology the
essentials, 2nd ed. Baltimore,Williams &
Wilkins, 1988
• Glanz K, et al: Health Behavior and Health
Education, 2nd 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