incidence of coronary events = rate of occurrence of totality of fatal & non-fatal events
strictly speaking incidence should refer only to 1st event not recurrences but these are often lumped together in which case should be referred to as event rates
mortality from coronary heart disease is usually measured as annual umber deaths per 100,000 pop.
case fatality = risk of death after an event (ie. proportion who die within a set period after an event)
USA:
1 million deaths per year = 50% of all deaths
160,000 deaths occurred in people < 65 yrs old (45% of all AMI's occur in this age group)
2/3rds of sudden deaths ffrom IHD occur outside hospital & usually within 2hrs of onset of symptoms
>50% are women
5 million years of potential life is lost per year due to cardiovascular disease & costs > $US100b/year
there has been a 54% reduction in age-adjusted mortality from IHD from 220/100,000 pop. in 1963 to 101/100,000 pop. in 1990:
25% fall in incidence
25% fall in case fatality rate:
30% mortality pre-CCUs
15% mortality post-CCUs
12.5% mortality post-CCUs with emphasis on decreasing MVO2
5% mortality with introduction of thrombolytic therapy
cocaine abuse:
accounts for ~25% of non-fatal AMI's in those aged 18-45yrs with peak age of 32yrs
relative risk of AMI is 24x during the 1st hour after use
Australia:
mortality rates per 100,000:
1950-1970:
men aged 20-69:
all causes: ~700
all cardiovascular: ~350
coronary heart disease: ~230
stroke: ~50
women aged 20-69:
all causes: 460 declining to 380
all cardiovascular: 210 declining to 160
coronary heart disease: ~75
stroke: 75 declining to 40
since 1970 there has been a steady decline in mortality such that by 1994:
men aged 20-69:
all causes: 390 (46% fall from 1967)
all cardiovascular: ~100 (67% fall from 1967)
coronary heart disease: ~90 (69% fall from 1967)
stroke: ~15? (73% fall from 1967)
women aged 20-69:
all causes: ~230 (46% fall from 1967)
all cardiovascular: ~40 (71% fall from 1967)
coronary heart disease: ~25 (71% fall from 1967)
stroke: ~10 (77% fall from 1967)
28 day AMI case fatality rates in Australia:
31% in 1960's, 25% in 1970's, 18% in 1980's
under 65yrs: 10.7% 1984-6; 8.4% 1987-9; 7.5% 1990-2;
emerging risk factors for an acute coronary syndrome include:
elevated C-reactive protein as a sign of underlying chronic inflammation related to elevated levels of interleukin-6 (reduced by statin therapy)
raised homocysteine
amyloid A
low activity of interleukin-1 (raises LDL, 15% incr. risk IHD, also risk for AAA)
genetic
drugs such as anakinra
mercury
sleep-disordered breathing
coffee (only in slow-caffeine metabolisers!)
Intake of coffee was associated with an increased risk of nonfatal AMI only among individuals with slow caffeine metabolism (odds ratio 2.3 (CI 1.4-3.9) for those aged < 59yrs drinking 4 or more cups of coffee per day). ref
obesity (using waist-to-hip ratio not simply BMI).
Consumption of alcohol of any type 3-4 times a week appears to be protective. ref
high blood levels of the artificial sweetener erythritol (this is commonly used in Zero sugar drinks) appears to double risk of stroke and heart attacks 1)
taking a family history:
consider:
number of relatives at risk & their sex, age & age at which they developed disease
whether another explanation for coronary disease (eg. smoking, diabetes) exists
when is a 'positive' FH really STRONG?
several of 1st degree relatives have been affected
disease developed at a young age (< 65yrs)
cases include females
affected persons didn't smoke
when is a 'negative' FH really PROTECTIVE?
family is large, yet few developed disease
most members lived to a ripe old age
no disease develops despite a large number of smokers