# Presentation: 102551

## 2007 Heart Disease and Stroke Prevention States Programs

- Edward J. Roccella, Ph.D., M.P.H.
- Centers for Disease Control and Prevention
- Atlanta, Georgia
- September, 19, 2007

## CVD-Major Public Health Problem

- 40% of all deaths-930,000 Americans
- 71 million- one or more types of CVD
- 2010-30 #Survivors of HD-increase faster than the US population
- 6 million hospitalizations
- Direct/Indirect Cost (2006) $403.1B
- 1 in 4 Have HBP-

## Hypertension Affects Target Organs

- Angina pectoris
- Unstable angina
- Myocardial infarction
- Sudden death
- Heart failure

- TIA
- Ischemic stroke
- Hemorrhagic stroke

- Renovascular disease
- Renal failure

- Claudication
- Aneurysm
- Critical limb ischemia

**Hypertension**

## 1976-98 Cumulative Incidence of Hypertension in Women and Men Aged 65 Years

**1976-98 Cumulative Incidence of Hypertension ****in Women and Men Aged 65 Years**

-  JAMA.2002;287:1003–1010.

**Years of Follow-up**

**Risk of Hypertension %**

**Years of Follow-up**

**Risk of Hypertension %**

## CVD-Hypertension

- Preventable
- Treatable
- Controllable
- Why is so Difficult to Do?

##               Models of                    Helping and Coping*

**Self**

**Self**

**Other**

**Other**

**Responsibility for a Problem****(Who is to blame?)**

**Responsibility for a Solution****(Who will control the future?)**

**Enlightenment Model**
- Person feels guilty
- Person needs discipline

**Compensatory Model**
- Person feels deprived
- Person needs power (skill)

**Moral Model**
- Person feels lazy
- Person needs motivation

**Medical Model**
- Person feels ill
- Person needs treatment

- * Brickman, *American Psychologist* *37*(4):368–384, April 1982.

## “Cured” Model

- Patient cooperates with  doctor, and BP is controlled. Patient told, “It’s okay now.”

- Drops out

- Patient stops medicine and visits.

- Patient doesn’t understand the difference between control and cure.  He thinks he’s “cured”.

- Patient receives no re-education about the lifelong need for treatment.

- Patient believes doctor meant “Stop taking the medicine” when he said, “You’re under control.”

- Belief that he’s “cured” and “told to stop medicine” is reinforced.

- Patient believes
- His diagnosis
- Hypertension is serious
- In the efficacy of medicine
- He can control HBP with doctor’s help.

- Patient doesn’t want to think of himself as “sick.”

- Patient receives no call from doctor.

## Nervous Tension Model

- Patient believes
- His diagnosis
- In medicine and its efficacy to lower blood pressure
- In the need for lifelong treatment
- In the hazard of HBP if left uncontrolled

- Patient believes hypertension is “nervous tension.”

- Patient believes he can control HBP with “self-discipline” or by “accepting life.”

- Patient feels no need to see doctor and keep appointments because he knows when to take medicine.

- Drops out

- Medical system does not follow up to recall patient for appointments.

- Patient has no symptoms to tell him that blood pressure is uncontrolled.

- Patient believes medicine is needed only to lower blood pressure, not to *keep* it low.

- Patient believes he can tell when BP is high since he knows when he is tense.

- Patient takes medicine when he feels tense and believes this adequately lowers BP.

- Patient believes he’s adequately controlled—reinforced by lack of professional intervention.

- Remains Uncontrolled

## What is Hypertension?

- 160/95 mm Hg?
- 140/90 mm Hg?

## Distribution of Blood Pressures in Adults in the United States

**95th  percentile**

- Source:  NHANES II

**90th percentile**

## Stroke Rates by Blood Pressure Level

- Source:  Framingham Heart Study, 1980

## Mortality Due to CHD per Quartile of Systolic BP

- Van den Hoogen PCW, et al, for the Seven Countries Study Research Group. *N Engl J Med*. 2000;342:1-7.

- Mortality Due to CHD per Quartile of Systolic BP

- 140

- Mortality From CHD
- (No./10,000 Person Years)

- 130

- 120

- 110

- 100

- 90

- 80

- 70

- 60

- 50

- 40

- 30

- 20

- 10

- 0

- 110

- 120

- 130

- 140

- 150

- 160

- 170

- Systolic Blood Pressure (mm Hg)

- United States
- Northern Europe
- Mediterranean southern Europe
- Inland southern Europe
- Serbia
- Japan

## “Natural History” of 35 yr old White malewith Untreated Hypertension

## Baseline Systolic Blood Pressure and

**All Cause Mortality Rates for 347,978 Men**

- Source: MRFIT. Stamler J. Hypertension 1991.

- 	Systolic Blood		Relative	Excess	Percent of All
- 	Pressure (mm Hg)	Rate	Risk	Deaths	Excess Deaths

- 	<110	39.4	1.00	0	0.0
- 	110-119	42.2	1.06	180	2.9
- 	120-129	45.9	1.16*	689	11.1
- 	130-139	52.7	1.34*	1226	19.7
- 	140-149	62.9	1.60*	1341	21.5
- 	150-159	80.4	2.03*	1204	19.3
- 	160-169	88.8	2.23*	669	10.7
- 	170-179	114.8	2.70*	430	6.9
- 	180+	144.2	3.42*	489	7.9

- *Adjusted rate per 10,000 person-years; average follow-up is 11.6 years.

- 33.7%

- 74.5%

## Stroke Mortality Rate 

**Stroke Mortality Rate**** **

**Stroke mortality rate in each decade of age versus usual blood pressure at the start of that decade.**

- Lancet 2002; 360: 1903-13

## Population-Based Strategy

**Population-Based Strategy**

- Hypertension 1991;17:I-16–I-20.

- % Reduction in Mortality

- Reduction in BP

**After Intervention**

**Before Intervention**

- Stroke	CHD	Total
- -6	-4	-3
- -8	-5	-4
- -14	-9	-7

- SBP Distributions

## Sodium Intake and BP

- Average American consumes_x000e_~4000 mgs Na daily
- Daily decrease in Na intake of 100 mmol would reduce BP 5.8/2..3 in Htn and 2..3/1.4 not Htn
- DASH diet plus Na reduced BP 11.5/5.7 and 7.1 and 3.7
- APHA, AMA, JNC et.al- 50%  reduction of Na in food supply

## SOURCES OF DIETARY SALT

**SOURCES OF DIETARY SALT**

- Processed Food

- Water

- Cooking Salt

- Table Salt

- Other
- Sodium

- Source: James et al. The dominance of salt in manufactured food in the sodium intake
-              of affluent societies. *Lancet* 1987;8530:426-428.

| Modification | Approximate SBP Reduction
(range) |
| --- | --- |
| Weight Reduction | 5-10 mmHg/10kg |
| Adopt DASH eating plan | 8-14 mmHg |
| Dietary sodium reduction | 2-8 mmHg |
| Physical activity | 4-9 mmHg |
| Moderation of alcohol consumption  | 2–4 mmHg |

**Lifestyle Modifications**

## Public Health Approaches to CVD  

**Public Health Approaches to CVD  **

**Public health approaches, (e.g. reducing calories, saturated fat, and salt in processed foods) can achieve a downward shift in a population’s BP. **
**Reducing overall BP by only a few mm Hg could affect overall CVD morbidity and mortality by as much or more than treatment alone.**
**Public Health approaches provide an attractive opportunity to interrupt and prevent the costly cycle of managing hypertension and its complications.**