医院心血管流病状况.ppt

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1、控制危险因素预防我国心血管病流行,我国心血管病防控：形势不容乐观,2006 中国慢性病报告,中国死亡原因(per 100,000;age 40),男性恶性肿瘤(374.1)心脏疾病(319.1)脑血管疾病(310.5)意外事件(54.0)感染性疾病(50.5),女性心脏疾病(268.5)脑血管疾病(242.3)恶性肿瘤(214.1)肺炎和流行性感冒(45.9)感染性疾病(35.3),Gu DF,NEJM 2006;353:1124-1134,随年龄增加，冠心病的危害增加,30岁组出现明显增高，占总DALY值的 28.94%70岁和80岁年龄组最高,占总DALY值的 49.33%,中国公共卫生

2、2008;24(1):1449-50,50403020100,0 5 15 30 45 60 70 80,年龄（岁）,Daly（人年/千人）,男性女性,我国冠心病的发展趋势,中国60岁年龄组人群的冠心病患病人数,http:/,中国心血管疾病,Murray 349:1347,Cardiovascular diseases in China,Murray 349:1347,我国心血管疾病负担日益严重,心血管病直接医疗费用支出急剧增加,1993年：187.44亿2003年：1301.17亿（6.94倍）,3 M died of CVD each year(45%total mortality),Ch

3、inese CVD statistics 2005,我国心血管死亡与危险因素的形势严峻,INTERHEART Study:Effect of Potentially Modifiable Risk Factors Associated with Myocardial Infarction in 52 Countries,Risk factorPARSmoking36%Diabetes12%Hypertension23%Abdominal obesity34%Psychosocial29%Veg/fruit daily13%Exercise26%Alcohol intake14%ApoB/Apo

4、A-1ratio(5vs1)54%All above combined90%,Yusuf et al,on behalf of the INTERHEART Study Investigators Lancet,2004;364 Pages 937-952,16,8,4,2,1,1-5,6-10,11-15,16-20,21-25,26-30,31-40,41,Never,Odds ratio(99%CI),Numbers smoked per day,Number of controlsNumber of casesOdds ratio,7489,727,1031,446,1058,96,2

5、30,168,56,4223,469,1021,1,623,1832,254,538,459,218,1-38,2-10,2-99,3-83,5-80,5-26,6-34,9-16,1210,1206,1208,1207,1210,1209,1207,1208,1208,435,496,610,0-43,720,790,893,1063,1196,1366,0-53,0-60,0-66,0-72,0-85,0-93,1-04,1-28,1209,1757,0-78,Number of controlsNumber of casesMedian,Odds ratio(99%CI),0-75,2,

6、3,4,5,6,7,8,9,1,10,1,2,4,8,ApoB/A1 ratio(deciles),INTERHEART Study:来自与心肌梗死有关的52中心汇总了潜在的可以改变的危险因素,Risk factorPAR抽烟 36%糖尿病 12%高血压 23%下腹肥胖症 34%精神性疾病 29%每日的蔬菜/水果13%运动减少26%酒精摄入14%ApoB/ApoA-1ratio(5vs1)54%所有上述综合累加 90%,Yusuf et al,on behalf of the INTERHEART Study Investigators Lancet,2004;364 Pages 937-95

7、2,16,8,4,2,1,1-5,6-10,11-15,16-20,21-25,26-30,31-40,41,Never,Odds ratio(99%CI),Numbers smoked per day,Number of controlsNumber of casesOdds ratio,7489,727,1031,446,1058,96,230,168,56,4223,469,1021,1,623,1832,254,538,459,218,1-38,2-10,2-99,3-83,5-80,5-26,6-34,9-16,1210,1206,1208,1207,1210,1209,1207,1

8、208,1208,435,496,610,0-43,720,790,893,1063,1196,1366,0-53,0-60,0-66,0-72,0-85,0-93,1-04,1-28,1209,1757,0-78,Number of controlsNumber of casesMedian,Odds ratio(99%CI),0-75,2,3,4,5,6,7,8,9,1,10,1,2,4,8,ApoB/A1 ratio(deciles),在中国超过 80%发生缺血性心血管疾病(CHD+脑卒中)的风险归结于以下主要危险因素,高血压 35%,抽烟32%,高胆固醇血症11%,糖尿病3%,*调节年

9、龄、性别之后,Other,Over 80%of ischemic cardiovascular diseases(CHD+ischemic stroke)risk in China is attributed to major risk factors,Population Attributable Risk(PARP),Hypertension 35%,Smoking32%,Hypercholesterolemia11%,Diabetes3%,*Adjusted for age,sex,the China MUCA Study Cohort,Other,中国心血管病流行的主要风险因素data

10、 from the National Nutrition and Health Survey in 2002,Prevalence of CVD major risk factors in China，data from the National Nutrition and Health Survey in 2002,Trends in Prevalence of hypertension,中国高血压患病率,(%),Wang Longde.Report of National Survey of Nutrition and Health Status 2002,第四次全国膳食和营养调查,我国高

11、血压现状：三高三低,2004年中国居民营养与健康状况调查报告,三高,三低,在中国，胆固醇水平不断攀升,数据来自WHO网站,（n=451）,（n=210）,（n=399）,%,不同疾病患者治疗后达标率,我国血脂异常治疗现状的调查-1999,陶寿淇.中华心血管病杂志.2001;29:15-17,中国患者血脂控制总体达标率仅为5012城市2237例患者最新资料,依据2007中国成人血脂异常防治指南标准进行分组,第二次中国临床血脂控制达标率及影响因素多中心协作研究。中华心血管病杂志。2007;35(5):420-427.,LDL达标率,中国抽烟流行情况,男,女,抽烟人数,%,%,1984,258,42

12、2,61.0,261,178,4.2,1996,65,000,63.0,57,000,3.8,a:Weng X,et al:Data from 1984 National Smoking Survey.b:Yang G.Smoking and Health in China:1996 National Prevalence Survey of Smoking Pattern.Beijing,China Science and Technology Press,1997.C:Wang L,ed.Series report#1,Chinese Nutrition and Health Status

13、 Report,p49,2005,抽烟人数,2002,73,193,53.9,87,360,3.1,Prevalence of Smoking in China,Men,Women,Number ofParticipants,%,%,1984,258,422,61.0,261,178,4.2,1996,65,000,63.0,57,000,3.8,a:Weng X,et al:Data from 1984 National Smoking Survey.b:Yang G.Smoking and Health in China:1996 National Prevalence Survey of

14、 Smoking Pattern.Beijing,China Science and Technology Press,1997.C:Wang L,ed.Series report#1,Chinese Nutrition and Health Status Report,p49,2005,Number ofParticipants,2002,73,193,53.9,87,360,3.1,吸烟是国人CVD第二大危险因素,35%,32%,67%,中国烟草消耗量列全球之首,1997年世界烟草消耗量统计,中国的肥胖问题日益凸显,Overweight:29.9BMI25 Obesity:BMI30,Ov

15、erweight:27.9BMI24 Obesity:BMI 28,Wang Y,et al.Int J Obes(Lond).2007;31(1):177-88.,Time Magazine 2002,糖尿病危害日趋严重,在亚洲糖尿病正在快速地增加,Source:IDF 2005,The metabolic syndrome(IDF criteria)is common in older Chinese people,He Y et al,JACC 37;2006,1980-2000，美国冠心病死亡呈现下降趋势,ES.Ford et al.N Engl J Med 2007;356:2388

16、-98,美国CHD死亡下降的重要经验:遵循循证证据，控制危险因素,ES.Ford et al.N Engl J Med 2007;356:2388-98,心血管疾病的预防需要多学科的合作,2007ESC CVD 预防指南,2007 WHO心血管危险评估与管理指南,Part I.The total risk approachto prevention of cardiovascular diseasePart II.Recommendations for prevention ofcardiovascular disease,强调多重危险因素的全面控制,男性,女性,高血压患者常常有多重心血管危险

17、因素,Kannel WB.Am J Hypertens.2000;13(1 Pt 2):3S-10S.,中国35-64岁人群2种心血管病危险因素的组合构成,1=高血压2=血脂异常3=糖代谢异常4=肥胖5=吸烟,28%,17%,16%,10%,8%,6%,5%,5%,4%,2%,血脂异常+吸烟,高血压+血脂异常,高血压+吸烟,中国35-64岁人群3种心血管病危险因素的组合构成,1=高血压2=血脂异常3=糖代谢异常4=肥胖5=吸烟,23%,21%,11%,10%,10%,9%,6%,5%,4%,2%,高血压+血脂异常+吸烟,高血压+血脂异常+肥胖,高血压+血脂异常+糖代谢异常,总体心血管危险的威胁

18、,Kannel WB.In:Genest J,et al,eds.Hypertension:Physiopathology and Treatment.New York,NY:McGraw Hill;1977:888-910.,Risk shown above is compared with risk for a 40-year-old male nonsmoker withTC 4.7 mmol/L(185 mg/dL),SBP 120 mm Hg,and no glucose intolerance,ECG-LVH negative,whose probability of develo

19、ping CVD is 15/1000(1.5%)in 8 years,血脂异常TC 5.4 mmol/L(210 mg/dL)X1.3,高血压SBP 165 mm HgX1.9,糖耐量异常X1.8,X2.6,X4.5,X3.5,X2.3,血脂异常TC 6.1 mmol/L(235 mg/dL)X1.7,高血压SBP 195 mm HgX3.0,吸烟X1.7,X5.3,X8.7,X5.2,X2.9,缺血性心血管病10年发病危险评估表,我国如何有效防控心血管疾病？,预防为主，综合控制危险因素，推动防线前移充分利用循证证据，遵守指南推动多学科合作,Current Guidelines for th

20、e Prevention of Cardiovascular DiseaseTy J.Gluckman,James Mudd,Catherine Campbell,Gregg Fonarow,&Roger S.Blumenthal,ABC Approach to Prevention,心血管疾病预防的内容,Cigarette smoking cessationBlood pressure controlLipid management to goalPhysical activityWeight management to goalDiabetes management to goalAnti

21、platelet agents/anticoagulantsRenin angiotensin aldosterone system blockersBeta blockersInfluenza vaccination,Antiplatelet Therapy Guidelines,Aspirin Recommendations,Aspirin(75-162 mg daily)in intermediate risk(10 year risk of CHD 10%)menAspirin in intermediate risk(10 year risk of CHD 10%)womenAspi

22、rin in low risk women(10 year risk of CHD 10%),Primary Prevention,CHD=Coronary heart disease,Aspirin Recommendations(Continued),Aspirin(75-162 mg daily)if known CHD/ASVDAspirin(100-325 mg daily)following CABG surgery*,Secondary Prevention,ASVD=Atherosclerotic vascular disease,CABG=Coronary artery by

23、pass graft,CHD=Coronary heart disease,*To be administered within the first 48 hours after surgery in order to reduce the risk of saphenous vein graft failure.Doses 162 mg/day may be continued for up to one year,对高血压患者降低血压的目标值 应降至140/90mmHg以下，有糖尿病、冠心病、肾功能不全者降至130/80mmHg,抗高血压药物的选择,Cholesterol Manageme

24、nt Guidelines,中国成人血脂异常防治指南,血脂异常患者开始治疗标准值及治疗目标值mg/dl(mmol/L),LDL-C 80(2.07),LDL-C 80(2.07),LDL-C 80(2.07),TC 120(3.11),TC 160(4.14),TC 120(3.11),极高危：急性冠脉综合征，或缺血性心血管病合并糖尿病,LDL-C 100(2.59),LDL-C 100(2.59),LDL-C 100(2.6),TC 160(4.14),TC 160(4.14),TC 160(4.14),高危：CHD或CHD等危症，或10年危险性1015,LDL-C 130(3.37),LD

25、L-C160(4.14),LDL-C 130(3.37),TC 200(5.18),TC 240（6.22）,TC 200(5.18),中危：(10年危险性5-10),LDL-C 160(4.14),LDL-C 190(4.92),LDL-C 160(4.14),TC240(6.22),TC270(6.99),TC240(6.22),低危：(10年危险性5%),治疗目标值,药物治疗开始,TLC开始,危险等级,ESC/EASD新指南关于糖尿病治疗目标,参数 治疗目标改变生活方式 系统性教育戒烟 强制性 血压 1.0；女性 1.240；76甘油三酯1.7150,Angiotensin Conver

26、ting Enzyme Inhibitor Guidelines,ACE Inhibitor Recommendations,An ACE inhibitor in those following a MI,regardless of EF or in those with CAD*along with hypertension(SBP 120 mmHg),LVSD(EF 0.40),heart failure,DM,or CKDOptional use of an ACE inhibitor in those with low risk CAD*,well controlled risk f

27、actors,normal EF,and successful revascularization,Secondary Prevention,*Defined by previous MI or angiographically significant CAD,ACE=Angiotensin converting enzyme,CAD=Coronary artery disease,CKD=Chronic kidney disease,CV=Cardiovascular,DM=Diabetes mellitus,EF=Ejection fraction,LVSD=Left ventricula

28、r systolic dysfunction,MI=Myocardial infarction,SBP=Systolic blood pressure,Angiotensin Receptor Blocker Guidelines,Angiotensin Receptor Blocker Recommendations,Secondary Prevention,An ARB in those with asymptomatic LVSD(EF 0.40)or DM following a MI who can(Class IIa,Level B)or cannot(Class I,Level

29、B)tolerate an ACE-IAn ARB in those with symptomatic LVSD(EF 0.40)and intolerance of an ACE-IAddition of an ARB to an ACE-I in those with symptomatic HF or LVSD(EF 0.40),ACE-I=Angiotensin converting enzyme inhibitor,ARB=Angiotensin receptor blocker,EF=Ejection fraction,HF=Heart failure,LVSD=Left vent

30、ricular systolic dysfunction,MI=Myocardial infarction,b-blocker Guidelines,b-blocker in all patients following MI or ACSb-blocker in all patients with LVSDb-blocker in those with other forms of CV disease or DM,unless contraindicated,*Relative contraindications include asthma,chronic obstructive pul

31、monary disease,insulin dependent diabetes mellitus,severe peripheral arterial disease,and a PR interval 0.24 seconds,ACS=Acute coronary syndrome,CV=Cardiovascular,DM=Diabetes mellitus,LVSD=Left ventricular systolic dysfunction,MI=Myocardial infarction,b-blocker Recommendations*,Secondary Prevention,

32、治疗性生活方式改变(TLC)的基本要素,包括足够的中等强度锻炼，每天至少消耗200k热量,体力活动,调节到能够保持理想的体重或能够预防体重增加,总热量,1025克/日,可溶性纤维素,2克/日,植物固醇,能够降低LDL-C的膳食成分,200mg/日,膳食胆固醇,总热量的7,饱和脂肪酸*,使LDL-C增加的营养素,建议,要素,*反式脂肪酸也能够升高LDL-C，不宜多摄入。,二级预防,心理社会因素家族易患素质,血脂高血压戒烟糖尿病初级预防,运动健康饮食理想体重,阿斯匹林ACEI阻断剂康复 一级预防,一级预防,初级预防,Benjamin et al.JACC2002;40(4):579-651,CVD

33、预防-概念性框架,先决因素知识态度信仰,影响因素卫生资源-保险健康行为技巧-例如阅读食品 标签,强化因素社会支持,坚持CVD预防建议进入并持续关切 识别危险因素-采用健康的生活方式 服用抗CVD危险因素的药物 协助使之依从良好,健康结局初级预防(Primordial Prevention)保持理想的体重健康饮食规律的体力活动戒烟1。和2。预防达到最佳的-血压-血脂-血糖控制生活远离CVD,Benjamin et al.JACC2002;40(4):579-651,总 结,心血管疾病的防治重点早：危险因素人群及早干预综合：多重危险因素综合干预强化：高危人群强化干预持续：终生管理制定指南，推广指南，执行指南,