Cardiovascular Disease Prevention 心血管疾病预防 Jason Logan, MD 刘杰森.

Presentation on theme: "Cardiovascular Disease Prevention 心血管疾病预防 Jason Logan, MD 刘杰森."— Presentation transcript:

1 Cardiovascular Disease Prevention 心血管疾病预防 Jason Logan, MD 刘杰森

2 Overview 概要 Introduction 介绍 Why is CVD Prevention important? 心血管疾病预防为什么重要？ How do we do it? 我们怎么做？ How do we teach others: patients/residents? 我们怎么教其他 人：病人 / 住院医师？

3 Introduction 介绍 1.Who am I? 我是谁？ 2.Where am I from? 我从哪里来 3.Why am I here? 我为什么来这 里？

4 Who am I? 我是谁？ My wife and I are Board Certified Family Medicine Physicians 我和我妻子是家庭医师学会认证的家庭医生。 Our family moved to Chengdu, China October 2008 from Tulsa, OK USA where we were teaching Family Medicine residents 我们全家于 2008 年 10 月从美国俄克拉荷马州的 Tulsa 市搬家到中国成都。我们曾在那里教家庭医学住院医生。 We have been studying Chinese and consulting at Hua Xi and hope to start teaching Family Medicine there soon 我们一 直在学汉语并且在华西做咨询，希望能在那里很快开始教家庭 医学。 We have 3 children: Jacob David, Lydia Grace, and Julia Faith 我们有 3 个孩子： Jacob David, Lydia Grace, and Julia Faith 。

5

6 Our Children

7 Julia Faith

8 Why am I Here? 我为什么来这里？ Good friends with Dr. Chris Place and Dr. Cassie Zhou 因为我是 Chris Place 医生和周医 生的好朋友 Love to Teach 喜欢教学 Want to help the wonderful people of China any way we can 想通过任何我们能做到的方式 来帮助这么好的中国人 I am excited about the moves made by the Chinese government with regards to Primary Care/Family Medicine 对于中国政府在基本医疗 / 家庭医学方面所做的发展工作，我感到很兴奋。

9

10 Cardiovascular Disease Prevention: 心血管疾病预防： 1. Why is it important? 为什么很重要？

11 Role Play #1 角色扮演 1

12 What is cardiovascular disease? (CVD) 什么是心血管疾病 ( CVD)? Includes Coronary Heart Disease (CHD), Cerebrovascular disease (stroke), and Peripheral vascular disease (PVD) 包括冠状动脉性心脏病 (CHD) 、 脑血管疾病（中风）和外周血管疾病。

13 循环系统， 动脉和静脉

14 Why is CVD prevention important? 为什么心血管疾病预防很重要？ #1 Killer in USA and the #1 killer in China 美 国第一号 “ 杀手 ” ，中国第一号 “ 杀手 ” The incidence in China has more than doubled since 1998 中国自 1998 年以来发 病率增加 2 倍多 As China becomes more wealthy- more CVD risk factors emerge 由于中国变得更富 有 - 因此有更多的心血管危险因素出现 Affects the productive middle-class of society 影响社会的中坚力量

15 Why is CVD increasing in China? 为什么中国的心血管疾病在增多？

16 The top five leading causes of death in China (2007) 中国 2007 年前 5 位死因 Rank 排名 Urban 城市 Rural 乡村 Disease 疾病 (ICD-10) Mortality 死亡率 (1/100,000) % Disease 疾病 (ICD-10) Mortality 死亡率 (1/ 100,000) % 1 Malignant tumor 恶性肿瘤 176.228.5 Malignant tumor 恶性肿瘤 114.224.8 2 Cerebrovascula r diseases 脑血 管疾病 111.518.0 Cerebrovascular diseases 脑血管疾 病 119.720.6 3 Heart diseases 心脏 疾病 100.616.3 Respiratory diseases 呼吸疾 病 100.216.2 4 Respiratory diseases 呼吸 疾病 80.913.1 Heart diseases 心脏疾病 86.014.8 5 Trauma/ Poisoning 创 伤 / 中毒 37.66.1 Trauma/ Poisoning 创伤 / 中毒 52.19.0

17 Hypertension in China: Lancet 11/09 高血压在中国：柳叶刀 2009 年 11 月 #1 Cause of preventable premature death 可预防的早 死亡的第一位原因 20% of all-cause mortality and 60% of cardiovascular mortality attributed to HTN 所有原因引起死亡的 20% 和心血管原因引起死亡的 60% 与高血压有关 Nationwide survey- only 24% of 153 million who had HTN, knew that they did 全国调查 -1.53 亿有高血压的人 中只有 24% 的人知道他们有高血压 Only 19% of those with HTN were receiving therapy 那些 高血压病人中只有 19% 的人正在接受治疗 Of those receiving therapy 24% achieved goals 正在接受治疗的人中只有 24% 的人达到治疗目标 Lancet 2009 Nov 21; 374(9703):1765-1772.

18 Asia Pacific Cohort Studies 亚太地区队列研究 An Asian CVD epidemic is inevitable with increasing cholesterol levels, obesity, and hypertension 随着胆固醇水平升高、肥胖和高血压增多，亚洲心血管疾 病流行不可避免。 “…many of the victims will be in the prime of their working lives, since heart disease strikes at a much younger age in Asia than in the West” Prof. S MacMahon “ 在亚洲，心 脏疾病出现的年龄较西方人更年轻，因此很多人会在他们 工作阶段的全盛期患病。 There is a Huge Potential to prevent CVD in China 在中国，预防心血管疾病具有极大的潜力。

19 全球近 2/3 的吸烟者居住在 10 个国家

20 Year 年 1984 19962002 2009 Total smoking rate 33.9% 37.6%35.8% (Aged>15) 总吸烟率（年龄 >15 岁） Male 男性 66.9%66.0% 48% Female 女性 4.2%3.08% 2.6% Smoking rate in 60.0% 56.8% male medical doctors 男性医生的吸烟率 Year 年 1984 19962002 2009 Total smoking rate 33.9% 37.6%35.8% (Aged>15) 总吸烟率（年龄 >15 岁） Male 男性 66.9%66.0% 48% Female 女性 4.2%3.08% 2.6% Smoking rate in 60.0% 56.8% male medical doctors 男性医生的吸烟率 Three National Prevalence Surveys 3 个全国流行率调查

21 Cardiovascular Disease Prevention: 心血管疾病预防 : 2. How do we do it? 我们怎么做？

22 Established CVD Risk Factors 已明确的心血管疾病危险因素 Non-modifiable 不可改变的 Age (M>45, F>55) 年龄（男性 >45 ，女性 >55 ） Male sex 男性 Positive Family History 有家族史 Modifiable 可改变的 Smoking 吸烟 Obesity 肥胖 Poor Diet 饮食差 Lack of Exercise 缺少体力活动 Dyslipidemia 血脂异常 Hypertension 高血压 Diabetes is a CVD Equivalent 糖尿病是心血管疾病的等危症

23 How do we do it? Modifiable Risk Factors 我们怎 么去做？可改变的危险因素 *** Lifestyle Changes are KEY***: *** 生活方式改变是关键 ***: Smoking, Obesity, Diet, and Exercise 吸烟、肥胖、饮食和体力活动 Hypertension 高血压 Dyslipidemia 血脂异常

24 INTERHEART study 2004 国际间心脏研究 2004 Global study- 52 countries 全球研究 -52 个国家 Over 90% of the risk for 1 st Acute MI due to 9 modifiable risk factors 发生第 1 次急性心肌梗死的危险中超过 90% 的危险是来自于 9 种可改变的危险因素 Dyslipidemia, smoking, hypertension, diabetes, obesity, psychosocial factors (stress), low consumption of fruits and vegetables, and lack of physical activity 血脂异常、吸烟、高血压、糖尿病、肥胖、心理社会因素 （压力）、食用水果和蔬菜少、缺少体力活动 Lancet 2004 Sep 11;364(9438):937-52. 柳叶刀 2004 年

25 Qingdao 2005 青岛 2005

26 Smoking 吸烟 Smoking is an independent major risk factor for CVD, CHD 吸烟是心血管疾病、冠心病的主要 独立危险因素 –Incidence of AMI increases 6x in women and 3x in men who smoke at least 20 cigarettes/day 急性心肌梗死发病率在每天至 少吸烟 20 支的女性中增加 6 倍，男性中增加 3 倍 Smoking increases all-cause mortality and Cardiovascular mortality 吸烟增加所有病因死亡率和心血管原因死亡率 Smoking accelerates the progression of CVD 吸烟加速心血管疾病的进程 Up to Date: Preventive Cardiology: Cardiovascular Risk of Smoking and Benefits of Smoking Cessation

27 Smoking Cessation 戒烟 Smoking cessation greatly decreases risk 戒烟大 大降低危险 –One year after quitting, the risk of MI and death from CAD is reduced by 50% 戒烟一年后，心肌梗死和其他 冠心病死亡的危险降低 50% 。 –After several years risk begins to approach that of non- smokers 戒烟几年后，危险开始达到非吸烟者的水平。 –IT IS VERY IMPORTANT TO EDUCATE YOUR PATIENTS AND ENCOURAGE SMOKING CESSATION!!! 对你的病人进行健康教育并鼓励他们戒烟非常重要！！！ Up to Date: Preventive Cardiology: Cardiovascular Risk of Smoking and Benefits of Smoking Cessation

28 Obesity 肥胖 Obesity contributes to Hypertension, dyslipidemia, and atherosclerosis 肥胖促进高血压、血脂异常和动脉粥样硬化。 Excess body weight accounts for 23% of cases of CAD in men and 15% of cases in women 超重与 23% 男性心血管病人和 15% 女性 心血管病人有关。 Abdominal distribution of body weight increases risk 腹型肥胖增加危险。 Up to Date: Primary Prevention of Cardiovascular Disease and Stroke

29 Exercise 锻炼身体 Even moderate exercise has a protective effect against CAD and all cause mortality 甚至只是适度的体力活动对冠心病和所有病 因的死亡率都具有保护作用。 Variety of beneficial effects 各种益处 –Increase HDL 升高 HDL （高密度脂蛋白） –Decrease blood pressure 降低血压 –Decrease insulin resistance 降低胰岛素 抵抗 –Weight loss 减轻体重 Up to Date: Primary Prevention of Cardiovascular Disease and Stroke

30 Diet: Mediterranean 饮食：地中海式 The Diet with the best CVD reduction evidence 是最具有降低心血管疾病证据的饮食 Increased intake of fruits and vegetables: 5+/day 增加了水果和蔬菜 的摄入： 5+/ 每天 Increased fiber 增加了膳食纤维 –40-50% Decrease in risk of CAD and stroke compared to low fiber diets 与低 纤维饮食相比，降低了 CAD 和中风危险 40-50% Decreased saturated and trans fat intake 减少了饱和脂肪和反式脂肪 摄入 Increase mono/polyunsaturated fat intake: Fish, Olive Oil, nuts, seeds 增加了单 / 多不饱和脂肪摄入：鱼、橄榄油、坚果、籽。 Decrease Salt 减少了盐 Benefits 益处 –Decreased LDL and Increased HDL 降低了 LDL 和增加了 HDL –Decreased blood pressure 降低了血压 –Weight loss 减轻了体重 Up to Date: Primary Prevention of Cardiovascular Disease and Stroke

31 Back 每天体力活动 面包、面食、米饭、麦片、玉米大麦粥、其它 全谷类和土豆 水果 蔬菜 每天 每周 每月 橄榄油 奶酪、酸奶 鱼 家禽肉 鸡蛋 甜品类 肉 每天饮料 建议： 6 杯水 适量葡 萄酒 豆类、坚果

32 Mediterranean Diet Systematic Review 地中海 式饮食系统回顾 1,574,299 subjects followed 3-18 years 157.4299 万受试者，随访 3-18 年 Reduced all cause mortality (RR 0.91) 降低了全因死亡率 (RR 0.91) Reduced CV mortality (RR 0.91) 降低了心血管死亡率 (RR 0.91) Reduced Cancer mortality (RR 0.94) 降低了癌症死亡率 (RR 0.94) Reduced Parkinson‘s disease and Alzheimer’s disease (RR 0.87) 降低了帕金森病和阿尔茨海默病 (RR 0.87) Sofi F et al. Adherence to Mediterranean diet and health status. BMJ 2008; 337:a1344. doi:10.1136/bmj.a1344.

33 Diabetes: CVD equivalent 糖尿病：心血管疾病等危症 Diabetics have a higher prevalence of CAD, a greater extent of coronary ischemia, and are more likely to have an AMI and/or a silent MI 糖尿病病人具有较高的冠心病患 病率，具有更大范围的冠状动脉缺血，更可能有急性心肌梗 死和 / 或静态的心肌梗死。 In DM1 approximately 35% have CAD by age 55 vs. 8% in male non-diabetics and 4% in female non-diabetics 1 型糖尿病病人中，年龄到 55 岁时大约 35% 会有冠心病，而 对于非糖尿病人群，男性是 8% ，女性是 4% 。 Aggressively manage associated risk factors: Lipids, Hypertension, and Lifestyle 要积极地处理伴随的危险因素：血脂、高血压和生活方式。 Up to Date: Epidemiology of and Risk Factors for Coronary Heart Disease in Diabetes

34 Cardiovascular Disease Prevention: 心血管疾病预防 3. How do we teach our patients and resident physicians? ： 怎样教我们的病人和住院医师？

35 How do we teach this to others? 我们怎样教他人？ Model/Mentor Healthy Lifestyle: No personal smoking or Obesity 塑造 / 指导健康的生活方式：自己不吸烟、不肥胖。 Discuss Lifestyle issues at every visit, especially smoking 每次就诊都要探讨生活方式问题，特别是吸烟。 Educational Posters in the office 在办公室设健康教育宣传栏 Write a Prescription for Healthy Lifestyle 写下健康的生活方式处方 Personalize advice 建议要个体化 Encourage patients to think about their children 鼓励病人去想一想他们的孩子

36

37 Healthy Lifestyle Prescription 健康的生活方式处方 20 minutes of exercise daily 每天 20 分钟体力活动 20 minutes of relaxation/prayer daily 每天 20 分钟放松 / 祷告 5 servings of Fruit/Vegetables daily (or true Mediterranean Diet for motivated people) 每天 5 份水果 / 蔬菜（或给有兴趣的人真 正的地中海式饮食） Avoidance of Smoking or other toxins 避免吸烟或其它毒物 Calculate patient’s BMI (kg/m 2 ) and show them their ideal weight to make their BMI 23 计算病人的体重指数 BMI (kg/m 2 ) ， 给他们看他们的理想体重，使他们的体重指数达到 23

38 Smoking Cessation Advice 戒烟建议 It Does Help! 确实有帮助！ 2008 Cochrane review compared brief advice, intensive advice, and usual care in regards to quit rates 6 months after advice 2008 Cochrane 回顾比较了简单建议、深入建议和常规 治疗 6 个月后的戒烟率 Brief advice better than usual care (RR 1.66) 简短建议 比常规治疗好 (RR 1.66) Intensive advice better than brief advice (RR 1.84) 深入建议比简短的建议好 (RR 1.84) Stead LF et al. Physician advice for smoking cessation. Cochrane Database Syst Rev 2008; Apr 16

39 基层医生帮助病人戒烟指南 策略 1 问诊：每次就诊要系统地问到吸烟的情况 对成功戒烟给予主要建议 策略 2 策略 3 策略 4 策略 5 建议：强烈促使所有吸烟者戒烟 。 以一种明确、坚决的个体化的态度，促使每个吸烟者戒烟。 明确吸烟者是否有试图戒烟的愿望。 询问每一个吸烟者是否愿意此时尝试戒烟。 帮助：为病人戒烟提供帮助 帮助病人制定戒烟计划。 鼓励在特别的情况使用尼古丁替代治 疗或安非拉酮。 实施一种办公系统，确保每个病人每次就诊时医生都会询问和记录吸烟状况。 提供补充材料 安排随访计划，或者面谈或者通过电话

40 “Doctor” from the Latin “docere” Meaning “To Teach” 拉丁语中医生的意思是 “ 教授 ”

41 Role Play #2 角色扮演 2

42 Thank You !!! 谢谢！ Any Questions? 有问题吗？

43 Cardiovascular Disease Prevention: 心血管疾病预防：病例和讨论 Case/Question Discussions

44 Case #1 病例 1 46 year old obese male (BMI 31) comes in for health screening and his blood pressure is noted to be 155/95 46 岁男性肥胖病人（体重指数是 31 ），他来门诊做健康筛查，他 的血压是 155/95 1.What CVD Risk Factors do you already know he has? 他已知的心血管疾病危险因素有哪些？ Male sex 男性 Age>45 年龄大于 45 岁 Obesity 肥胖 Hypertension 高血压

45 2. What would you like to ask him about? 你想问什么问题？ Family History of CVD/AMI? 心血管疾病家族史？ Dad died from a heart attack at age 47 父亲 47 岁死于心脏病发作 Smoking? 吸烟？ Smoke 2 packs/day 每天 2 包 Daily exercise? 每天锻炼吗？ I watch TV 我看电视 Current Diet? 当前的饮食？ 糖醋里脊 every night and sometimes McD 每晚吃糖醋里脊，有时候吃麦当劳 Recent lipid panel? 最近脂质化验情况？ Never had one 从来没做过

46 3. What advice can you give him? 你给他什么建议？ Begin work on a smoking quit plan 开始戒烟计划 20 minutes of brisk walking a day 每天快走 20 分钟 Don’t eat fatty foods or fast food 不吃油腻的食物及快餐 Increase fruits/vegetables- 5/day 增加蔬菜和水果 Check a lipid panel and some other basic labs 做脂质全项检查及一些基本实验室检查

47 Case #2 病例 2 A 37 year old Chinese woman has read some on the internet about the Mediterranean Diet but wants to know if it’s possible in China and how you would suggest doing it. You say….Mediterranean Diet 37 岁中国女性在网上读到有关地中海饮食的文章，她想直到在中国 是否可行，你给她什么建议？ 1.Eat Whole Grains- whole wheat bread, etc 吃全麦 - 全麦面包 2.Get 5+ servings of fresh fruits and vegetables daily 每天 5 份新鲜水果和蔬菜 3. Eat nuts/seeds daily 每天吃坚果和籽 4. Eat more fish and less beef/pork 多吃鱼少吃牛肉和猪肉 5. Use olive oil or at least Canola oil 使用橄榄油或至少用菜油 6. Stay away from deep fried foods and fast food 不吃煎炸食 物和快餐

48 Smoking Discussion 吸烟讨论 How do you encourage your patients to stop smoking? 你 如何鼓励病人戒烟？ Thinking of Chinese culture, what are some good ideas in counseling patients with regard to smoking or other lifestyle changes? 在中国的文化环境下，你有什么好办法给病人提供戒烟或 其他生活方式改变的建议？ Do you believe your interventions can benefit your patients and China as a whole? 你认为你的干预措施会让病人及中国整体受益吗？

49 Question #1 问题 1 A 60-year-old white female presents with pain in her left calf on walking. The pain does not go away with continued walking, and is relieved by rest. She smokes one pack of cigarettes daily and has type 2 diabetes mellitus which is only moderately controlled with oral agents. She has been fairly noncompliant with dietary measures, and has not been interested in following your recommendations regarding medication for her hyperlipidemia. She is unable to do many of the things that she previously enjoyed doing, such as playing golf. Her ankle-brachial index at rest on the left is 0.60 and on the right is 1.10. 60 岁白人女性来诊主诉走路时心前区疼痛。持续走路时疼痛不消失，但是休 息后疼痛缓解。她每日吸烟 1 包，患有 2 型糖尿病，用口服降糖药控制到中 等升高程度。她在饮食方面没有遵医嘱做调整，她对你给她高脂质血症开 的药也没有什么兴趣。她现在没法享受以前她本来很喜欢的一些活动，比 如打高尔夫。她休息时的踝胫指数是左侧 0.6 ，右侧 1.1.

50 Which one of the following is true regarding management of this patient’s peripheral vascular disease? 关于这个病人周 围血管疾病的问题下列哪项是正确的？ A. In order to improve functional capacity, exercise training should be encouraged 为了提高功能，鼓励运动训练 B. Her goal LDL-cholesterol level is <130 mg/dL 她的 LDL 目 标应该小于 1.47 C. Improved control of her diabetes with insulin will slow the progression of her disease 用胰岛素控制好她的糖尿病会 减慢疾病进展。 D. If she requires femoropopliteal bypass surgery, estrogen should be given postoperatively for secondary prevention 如果她需要做搭桥手术，术后应该给与雌激素，作为二级 预防措施。

51 Question #2 问题 2 Which one of the following treatments has been shown to produce the most benefit for patients with peripheral vascular disease? 下列哪项治疗会对有周围血管疾病的人有最 好的疗效？ A. Smoking cessation 戒烟 B. Diet modification 饮食调节 C. Aspirin 阿司匹林 D. Pentoxifylline (Trental) E. Lipid-lowering drugs 降脂药物

52 Question #3 问题 3 True statements regarding diet and coronary heart disease (CHD) include which of the following? 关于饮食和冠心病，下列哪项正确？ A. Reducing trans-fatty acid intake decreases the risk of CHD 减少反式脂肪酸摄入降低冠心病的风险。 B. Omega-3 fatty acids lower serum triglyceride levels and reduce thrombotic tendencyOmega-3 脂肪酸降低血清甘油三酯水平，减少栓塞的倾向。 C. Consumption of nuts raises LDL cholesterol 多吃坚果能提高 LDL 胆固醇 D. Fish which are particularly rich in omega-3 fatty acids include farmed salmon, anchovies, and herring 富含 Omega-3 脂肪酸的鱼包括三文鱼、沙丁鱼和鲱鱼 E. Trans-fatty acids are found primarily in foods containing fully hydrogenated oils 反式脂肪算主要在包含氢化油的食物中

53 Thank You !!! 谢谢！ Any Questions? 有问题吗？