Review
Copyright ©The Author(s) 2019.
World J Methodol. Jan 18, 2019; 9(1): 1-19
Published online Jan 18, 2019. doi: 10.5662/wjm.v9.i1.1
Table 1 Summary of landmark international and Australia coronary artery disease studies
Study geographyClinical summary (Population data available on). Demography; epidemiology; morbidity; mortality; regional variations in RF and outcomes; epidemiological transition; gaps
*Major international studies[6-8]Year, study, participants, sex and ethnicity:
US studies: (1946) The minnesota businessmen study – C, 281 M, < 55 yr; (1948) Framingham heart study - ; (1984) CARDIA – AA/C, 5115 M/F, 18-30 yr; (1987) ARIC – AA/C, 15792 M/F, 45-64; (1989) Strong Heart – AI, 4549 M/F, 45-75 yr; (1989) Cardiovascular health study – AA/C, 5888 M/F, 65-102 yr; (2000) Jackson heart AA, 5302 M/F, 21-94 yr; (2000) MESA AA/C/Ch/H, 6814 M/F, 45-80; (2006) Hispanic community health study/study of latinos – H, 15079 M/F, 18-72.
Global: 1958 The seven countries study – C, 12763 M, 40-59 yr; (1979) MONICA – ME; 15m M/F, 25-64 yr; (1999) INTERHEART – ME, 15152 M/F, age/sex matched; (2002) PURE – ME, 153996 M/F, 45-69 yr;
Japanese: (1965) Ni–Hon–San study – J, 20k M, 45-69 yr
Europe: UK: (1967, 1985)Whitehall, Whitehall II – C, 18403 M/10314 M-F, 40-64/35-55 yr; Iceland 1968, 2003) Rejkavik, AGES studies – C, 9141/2499 M, 34-79; Germany (1979) PROCAM – C, 4043M/1333F, 50-65
Summary of epidemiology findings:
Caucasian male population are baseline comparator group for epidemiology data
High income countries:
International trends shown strong ↓ mortality in high-income countries since 1980
Mortality gaps exist with ethnic differences (probably genetics) either ↑ or ↓ risk or even protection.
Globally:
Age-standardized acute myocardial infarction incidence and angina prevalence have ↓ and ischemic heart failure prevalence has increased since 1990 (6)
High age-standardized IHD mortality in Eastern Europe, Central Asia, and South Asia point to the need to prevent and control established risk factors in those regions and to research the unique behavioral and environmental determinants of higher IHD mortality.(7)
Much of the dramatic CHD mortality increases in Beijing can be explained by rises in total cholesterol, reflecting an increasingly “Western” diet. Without cardiological treatments, increases would have been even greater.(6-4 Critchley J)
Gaps in knowledge:
Paucity of data in older > 75 yr
Ethnic, family and true genetic contributions to CAD with improved modifiable risk factor control
Australia[17,18]Mortality, morbidity and cost:
Death rates >Japan but < other high-income countries e.g. UK, Germany USA
ATSI Deaths 1.5-3 x and IHD burden.0 0Smoking ATSI
Ischaemic heart disease results in more. Australian deaths than any other single cause for both men and women.
Death rates from heart disease are substantially higher among ATSI Australians, ranging from 1.5 to 3 times higher than in non-Indigenous Australians.
Of all Australians aged 2 yr and over, 5% report living with heart, stroke or vascular disease. Among people aged 85 yr and over, this proportion rises to two in every five people (40%).
In 2012–2013 the Pharmaceutical benefits scheme paid approximately $1.8 billion for cardiovascular system medicines, representing 21% of total benefits paid in that year.
Risk factor:
↓ Smoking M:F18:14%: ATSI > 2x double non-Indigenous (41% daily smokers).
< 10% of all met the NHMRC guidelines for vegetable consumption. In a national secondary school survey, 24% met recommendations for consumption of vegetables and 42% met recommendations for fruit consumption.
Most Australians (58%) were either sedentary or had low levels of activity. Australians spent an average of 38.8 only 30% of children met physical activity recommendations, and only 10% met both physical activity and screen-time recommendations.
13% of men and 10% of women reported drinking alcohol at levels likely to present a risk to health. Total per capita alcohol consumption fell between the early 1970s and the early 1990s, but has been relatively steady since then.
One-third of Australians had high blood cholesterol (above 5.5 mmol/L). Almost four in every five Australians with abnormal cholesterol or triglyceride levels were not receiving treatment for it.
One in five Australians had high blood pressure and the prevalence was higher in men than women. One in four Aboriginal and Torres Strait Islander Australians had high blood pressure. The prevalence of high blood pressure rose substantially with age, from less than 10% in the 25 to 34-year age group to almost 50% in people aged 75 years and over.
More than two-thirds of men were classified as overweight or obese, as were 55% of women. One-quarter of children aged 2 to 17 years were classified as overweight or obese.
The overall prevalence of diabetes in the Australian public was more than 5%, with a further 5% at increased risk of developing diabetes.
The prevalence of mental disorders in 2007 was 17.6% in men and 22.3% in women; anxiety disorders were the most prevalent mental disorders in both sexes. Cardiovascular disease was responsible for nearly 44000 deaths in Australia in 2012, including more than 20000 deaths from ischaemic heart disease.
Table 2 Sensitivity and specificity non-invasive test
TestGuideline indicationSensitivitySpecificityStress modalityAdvantageDisadvantage
ECG1st L-PTP45-5085-90PhysicalSimple and safeAccuracy
2nd I-PTPAvailabilityECG artifact
Lower costFalse positives
Echo1st L-PTP80-8580-88PhysicalSimple and safeSuboptimal image quality e.g., resting wall motion defects, lung disease, respiratory artifact,
2nd L-PTPPharma*AvailabilityImage capture within 90 sec of peak HR
Lower costCost of contrast
No radiation
ECG independent
Mobility independent*
Ischemia: Quantify and localize; greater spatial resolution (subendocardial)
Myocardial perfusion scintigraphy (SPECT, PET)1st L-PTP73-9263-87PhysicalAccurate quantification ischemic areaCost
2nd L-PTP90%75-87Pharma*Ischemia: Quantify and localize; greater spatial resolution (subendocardial)Availability
↑ accuracy with septal defectsRadiation and retesting
Ischemia: ↓spatial resolution e.g. for subendocardial ischemia
Pharma: CI, SE, ↓ sensitivity for multivessel disease
↑ acquisition time
Artifacts: Lung motion, breast tissue, diaphragm attenuation
MRI
Ischemia1st I-PTP79-8881-91Pharma*Body habitus/lung window independentCost
Perfusion2nd L-PTP67-9461-85AccurateAvailability
No radiationExpertise
Operator independence↓ Gating: Rhythm and rate
High spatial resolution
Can perform absolute quantification of perfusion
CA Score1st L-PTP95-9964-83Direct visualization coronary arteryAvailabilityRadiation
CTCA2nd I-PTPNon-invasiveCost
Anatomical informationCa score role
FFRNo functional information
Contrast
↓ Gating: Rhythm and rate