Horus University ……..

Community Medicine

Cardiovascular diseases (CVDS)

CVDs are disorders of the heart &/or blood vessels & includes:
1. Coronary heart disease (CHD): angina pectoris & myocardial infarction (MI)
2. Cerebro-vascular disease (stroke).
3. Hypertension.
4. Peripheral artery diseases.
5. Rheumatic heart disease.
6. Congenital heart diseases
7. Heart failure.

Global burden of CVDs:

Magnitude
1. Our world population in 2023 is 8 billion! Of these, around 620 million people are living
with heart and circulatory diseases across the world.
2. Globally it’s estimated that 1 in 13 people are living with a heart or circulatory disease.
Deaths
• The lead cause of mortality for men and women globally.
• Heart and circulatory diseases cause around 1 in 3 deaths globally
• Estimated 20.5 million deaths in 2021
• An average of 56,000 people each day or one death every 1.5 seconds
• Deaths from cardiovascular disease surged 60% globally over the last 30 years
Coronary Heart Disease (CHD)
[Ischemic Heart Disease (IHD); Coronary Artery Disease (CAD)]

Definition:
An impairment of heart function due to lack of oxygen supply to the myocardium,
caused by narrowing of the coronary arteries resulting from atherosclerosis.

Public health Importance:

• Coronary heart disease kills an estimated 9 million people each year
• In 2019 it was the world's single biggest killer.
• Around 1 in 6 deaths globally are caused by coronary heart disease.
• Before the coronavirus pandemic, coronary heart disease had been the leading cause
of death worldwide for at least 30 years.

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Clinical presentations:
1) Angina pectoris on effort.
2) Myocardial infarction.
3) Heart irregular rhythms.
4) Cardiac failure.
5) Sudden death.

CHD Risk Factors:

[I] Non-Modifiable risk factors:

These factors can’t be changed. However, it is important to identify high risk groups.
1. Age:
Atherosclerosis process progress with age.
The risk ↑among:
- Males > 45 years & females 55 >years of age.
- Young adult (20-30 years) smokers,

2. Sex: Male sex is at a higher risk.

Before menopause:
- Women are at lower risk (male to female ratio 10:1).
- This may be due to the protective effect of estrogen against atherosclerosis.
After menopause:
- ↑ risk for females & by the age of 50 to 55 years, it equalizes that of males.

3. Family history:
Higher risk in individuals with a history of MI or sudden death in:
- Father before the age of 45 years or
- Mother before the age of 55 years.

4. Genetic factors: play a role in dyslipidemia.

5. Type A personality:
Aggression, competition, impatience & time urgency.

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[II] Modifiable Risk factors:

A. Life style risk factors B. Diseases as risk factors:
(1) Dietary factors: (atherogenic diet) (1) Dyslipidemia:
High in: 1. ↑ total Cholesterol.
- Calories - total fat - saturated fats 2. ↑ LDL-C.
- Cholesterol - sodium - refined sugar. (low density lipoprotein cholesterol)
Low in: 3. ↑ Triglycerides.
- Whole grains - Cereals - Legumes 4. ↓ HDL-C.
- Vegetables - Fruits - Folic acid (high density lipoprotein cholesterol)
- Antioxidant vitamins - Fiber (2) Hypertension
- Omega-3 fatty acids. - A major risk factor for CHD.
(2) Physical inactivity & sedentary life: - Elevated cholesterol is essential for
Through ↑ CHD risk factors as: hypertension to be risk for CHD.
1- Obesity 3- dyslipidemia (3) Type 2 DM:
2- Hypertension 4- DM. - CHD is 2- 3 times higher in diabetics.
(3) Mental stress: can ↑CHD risk, e.g. - DM affects coronary blood vessels &
- Depression. – Anger. – Fear. lipoprotein metabolism:
- Anxiety. - Lack of social support. ↑LDL cholesterol & triglycerides
↓ HDL cholesterol.
(4) Smoking: - Diabetics have higher prevalence of
- It is atherogenic, sympathetic stimulator, hypertension & obesity.
enhances clotting & platelet adhesion.
- 20% of CVD is due to smoking (4)Obesity:
- Mortality from CHD is 60% higher in 1. central adiposity is more risky
smokers. 2. It ↑ risk for:
- Regular exposure to passive smoking ↑ - insulin resistance
CHD risk by 25%. - Type 2 DM.

(5) Alcohol consumption: ↑ risk of (5) Gout: hyperuricemia is a risk for CHD
dyslipidemia, hypertension & affects
clotting factors.

Emerging risk factors: C-reactive protein (CRP), fibrinogen, coronary artery calcification (CAC),
homocysteine, lipoprotein (a), & small, dense LDL.

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Prevention:
A- Primary prevention: (Prevention & management of risk factors)
Assessing & managing CVD risk in people with risk factors who have not yet
developed clinically manifest CVD.
[1] Lifestyle modification:
1) Control of diet:

2) Reduction of mass obesity (see nutrition).

3) Avoid smoking (anti-smoking program).
4) Avoid physical inactivity & mental over activity:
1. Physical exercise: at least 30 minutes of moderate intensity exercise (e.g.
walking) daily at least 5 days/ week.
2. Sports: outdoor & indoor.
3. Programs for community, industrial & work site:
- For community: open spaces, parks & indoor facilities.
- For industry: exercise break, sponsored sports & fitness programs.
4. Medical centers with staff & facilities for fitness evaluation & exercise
prescription for those impaired by age, weight, sedentary life & disabilities.

[2] Prevention & control of any underlying medical condition:

1- Hypertension
2- DM.
3- Hyperlipidemia: diet control, physical activity & lipid lowering drugs (statins)

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[3] Health education:

1. A component of all the above-mentioned preventive measures
2. Aim: to educate & motivate individuals & communities to achieve positive
healthy lifestyle changes.
3. Target population can be total population, specific group (e.g. industrial
workers) or high Risk Individuals.

B- Secondary Prevention:
Aim: prevent recurrent ischemic events in patients with coronary artery disease.
(1) Reassure the patient.
(2) Proper treatment with the following medications are necessary:
▪ aspirin ▪ angiotensin-converting enzyme inhibitors
▪ beta-blockers ▪ Statins.

In addition costly surgical operations are sometimes required:

▪ Coronary artery bypass grafting (CABG).
▪ Percutaneous transluminal coronary angioplasty (PTCA).
▪ Regular physical exercise.
▪ Reduction of risk profile.
▪ Gradually getting back into day to day life activities.
▪ Follow up & assessment at periodic intervals.

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Systemic Arterial Hypertension

Public health Importance:

- It is called the silent killer.
- It ↑ risk of CVDs (especially heart attack, heart failure, & stroke), resulting in
chronic illness, disability & premature death.
- Management of hypertension reduces mortality, stroke, CHD & heart failure.
- In Egypt, the national estimated prevalence of hypertension is 26%.
Risk factors
I- Non-modifiable factors:
Age:
1. The mean blood pressure ↑ with age.
2. Essential hypertension usually occurs among age group 25-55 years.
3. Secondary hypertension could occur at any age.
4. Tracking: it is the association of the current & future levels of blood
pressure. Individuals with low, normotensive & hypertensive range
tend to retain their relative rank with age.
5. Transient spikes of blood pressure in youth are associated with
↑in the risk of developing frank hypertension later on.
Sex:
Males have higher mean blood pressure (BP) till the age of 45yrs.
After the age of 45, the mean BP is higher among females than males.
Race:
More in blacks(May be due to: shared genetic factors or socio-economic factors).
Family aggregation:
There is aggregation of hypertension & similarity of blood pressure levels within families.
II .Modifiable risk factors
(1) High salt intake
(2) Obesity: more in obese persons.
(3) Sedentary life: leads to obesity & its risk for hypertension.
(4) Smoking: nicotine causes constriction of blood vessels.
(5) Alcohol consumption.
(6) Psychological factors: blood pressure regulatory mechanisms are sensitive to acute psychological
stimuli & strong emotional reactions.
( 7) Glucose intolerance.
(8) ↑ Serum uric acid.
Prevention:
[I] Primary prevention: (prevention & management of risk factors)
(1) Lifestyle modification: (Healthy lifestyle)
(2) Prevention & control of underlying medical condition, such as DM. (3) Health education: to ↑
awareness about risk factors, & to modify life style.
[II] Secondary prevention
Aim: Early case finding & treatment of hypertensive patients.
(1) At the high risk level: Detection & follow up by of high risk persons by periodic examination &
screening to keep BP within normal levels & management of hypertensive cases.
(2) The public level:
1- Health education: to arouse public interest in periodic medical exam, where broadline &
hypertensive cases can be screened & managed.

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3- Guidance of hypertensive cases: for treatment & management.

Difficulties with mass management of hypertension:

(1) Screening for all cases of increased BP in the population is practically difficult from the technical,
cost / benefit & manpower aspects.

(2) Two problems arise with management of screened cases:

A) Changing long-acquired faulty habits as dietary habits & smoking.

B) Long-term maintenance of antihypertensive therapy.

DASH
(Dietary Approaches to Stop Hypertension) is a flexible and balanced eating plan that helps create a
heart-healthy eating style for life.
The DASH eating plan requires no special foods and instead provides daily and weekly nutritional
goals. This plan recommends:
1. Eating vegetables, fruits, and whole grains
2. Including fat-free or low-fat dairy products, fish, poultry, beans, nuts, and vegetable oils
3. Limiting foods that are high in saturated fat, such as fatty meats, full-fat dairy products, and
tropical oils such as coconut, palm kernel, and palm oils
4. Limiting sugar-sweetened beverages and sweets