ΠΑΡΑΓΟΝΣΔ ΚΗΝΓΤΝΟΤ ΓΗΑ ΣΔΦΑΝΗΑΗΑ ΝΟΟ ΣΟΤ ΝΔΟΤ ΑΘΑΝΑΗΟ Ν. ΚΑΡΣΑΛΖ ΔΠΗΜΔΛΖΣΖ Α ΚΑΡΓΗΟΛΟΓΗΚΖ ΚΛΗΝΗΚΖ Γ. Ν. ΥΗΟΤ

Transcript

1 ΠΑΡΑΓΟΝΣΔ ΚΗΝΓΤΝΟΤ ΓΗΑ ΣΔΦΑΝΗΑΗΑ ΝΟΟ ΣΟΤ ΝΔΟΤ ΑΘΑΝΑΗΟ Ν. ΚΑΡΣΑΛΖ ΔΠΗΜΔΛΖΣΖ Α ΚΑΡΓΗΟΛΟΓΗΚΖ ΚΛΗΝΗΚΖ Γ. Ν. ΥΗΟΤ

2 H ΠΑΓΚΟΜΗΑ ΛΑΗΛΑΠΑ ΣΖ 3.8 εθ. άλδξεο θαη 3.4 εθ. γπλαίθεο εηεζίωο παγθνζκίωο πεζαίλνπλ από.ν. Δίλαη ε πξώηε αηηία ζαλάηνπ ζηηο πξνεγκέλεο ρώξεο. Data from WHO.org 2011 ΣΔΦΑΝΗΑΗΑ ΝΟΟΤ

3 ΣΑ ΔΛΛΖΝΗΚΑ ΓΔΓΟΜΔΝΑ WHO 2002

4 Total: 58.8million

5 Age in Years Ζ ΦΤΗΚΖ ΠΟΡΔΗΑ ΣΖ ΑΘΖΡΟΚΛΖΡΤΝΖ Myocardial infarct Cerebral infarct Gangrene of extremities Abdominal Aortic aneurysm Clinical horizon Calcification Complication lesion hemorrhage, ulceration, thrombosis Fibrous plaque Fatty steaks

6 ΜΔΛΔΣΔ ΜΔ ΑΤΣΟΦΗΔ ΓΔΗΥΝΟΤΝ ΟΣΗ Ζ ΣΔΦΑΝΗΑΗΑ ΑΘΖΡΟΚΛΖΡΤΝΖ ΔΗΝΑΗ ΠΑΡΟΤΑ ΣΖΝ ΖΛΗΚΗΑ ΣΧΝ 20 ΔΣΧΝ Study of Soldiers Killed in the Korean War 1950 s Enos WF et al. JAMA. 1953;152: Combat casualties in Vietnam 1970 s McNamara et al. in combat casualties in Vietnam. JAMA. 1971;216: Bogalusa Hearty Study- Atherosclerosis in Children Berenson GS et al.. N Engl. J Med. 1998;338: s-1990 s Pathobiological Determinants of Atherosclerosis in Youth 1980 s s Henry C. McGill et al. Circulation. 2000;102:

7 Bogalusa Heart study ΞΔΚΗΝΖΔ ΣΟ ΝΔΟΗ 2-39 ΔΣΧΝ ΘΔΧΡΔΗΣΑΗ ΓΗΑ ΣΑ ΠΑΗΓΗΑ ΣΟΟ ΖΜΑΝΣΗΚΖ ΟΟ Ζ FRAMINGHAM HEART STUDY ΣΟΤ ΔΝΖΛΗΚΟΤ

8 ASSOCIATION BETWEEN MULTIPLE CARDIOVASCULAR RISK FACTORS AND ATHEROSCLEROSIS IN CHILDREN AND YOUNG ADULTS for the Bogalusa Heart Study Autopsies on 204 young persons 2 to 39 years of age, who had died from various causes, principally trauma Gerald S. Berenson et al. N Engl J Med 1998; 338: J

9 ASSOCIATION BETWEEN MULTIPLE CARDIOVASCULAR RISK FACTORS AND ATHEROSCLEROSIS IN CHILDREN AND YOUNG ADULTS for the Bogalusa Heart Study Autopsies on 204 young persons 2 to 39 years of age, who had died from various causes, principally trauma Gerald S. Berenson et al. N Engl J Med 1998; 338: J

10 ASSOCIATION BETWEEN MULTIPLE CARDIOVASCULAR RISK FACTORS AND ATHEROSCLEROSIS IN CHILDREN AND YOUNG ADULTS for the Bogalusa Heart Study Autopsies on 204 young persons 2 to 39 years of age, who had died from various causes, principally trauma Gerald S. Berenson et al. N Engl J Med 1998; 338: J

11 Pathobiological Determinants of Atherosclerosis in Youth (PDAY study) ΞΔΚΗΝΖΔ ΣΟ 1985 ΝΔΟΗ ΚΑΗ ΝΔΔ ΔΣΧΝ ΘΑΝΑΣΟΗ ΚΤΡΗΧ ΛΟΓΧ ΑΣΤΥΖΜΑΣΧΝ 2876 ΠΔΡΗΠΣΧΔΗ ΤΓΚΔΝΣΡΧΘΖΚΑΝ

12 Figure 1. Extent of raised lesions in the right coronary artery and prevalence of AHA grade 4 or 5 lesions in the LAD McGill H C et al. Circulation 2008;117:

13 Association of Coronary Heart Disease Risk Factors With Microscopic Qualities of Coronary Atherosclerosis in Youth PDAY study Henry C. McGill et al. for the Pathobiological Determinants of Atherosclerosis in Youth (PDAY) Research Group Circulation. 2000;102:

14 Pathobiological Determinants of Atherosclerosis in Youth (PDAY study)

15 ΜΔΓΑΛΖ ΔΚΣΑΖ ΚΛΗΝΗΚΔ ΜΔΛΔΣΔ ΓΗΑ ΝΑ ΔΚΣΗΜΖΟΤΝ ΣΡΑΣΖΓΗΚΔ ΠΡΟΛΖΦΖ ΣΟΤ ΝΔΟΤ ΓΔΝ ΔΗΝΑΗ ΠΡΑΚΣΗΚΔ, ΓΗΑΣΗ ΑΠΑΗΣΔΗΣΑΗ: ΠΑΡΔΜΒΑΖ ΚΑΗ ΠΑΡΑΚΟΛΟΤΘΖΖ ΓΗΑ ΓΔΚΑΔΣΗΔ. ΜΔΓΑΛΟ ΑΡΗΘΜΟ ΑΣΟΜΧΝ, ΚΑΘΧ ΛΗΓΑ ΚΑΡΓΗΑΓΓΔΗΑΚΑ ΤΜΒΑΜΑΣΑ ΔΜΦΑΝΗΕΟΝΣΑΗ ΠΡΗΝ ΣΖΝ ΣΔΣΑΡΣΖ ΓΔΚΑΔΣΗΑ ΕΧΖ.

16 Chicago Heart Association Detection Project in Industry, E. Navas- Nacher et al. Annals of Internal Medicine 2001; 134: ΜΔΛΔΣΖΘΖΚΑΝ ΑΝΓΡΔ ΔΣΧΝ ΔΞΑΗΡΔΘΖΚΑΝ ΓΗΑΒΖΣΗΚΟΗ ΔΠΗΠΛΔΟΝ ΑΝΓΡΔ ΔΣΧΝ Χ ΟΜΑΓΑ ΔΛΔΓΥΟΤ ΠΑΡΑΚΟΛΟΤΘΖΖ ΓΗΑ 20 ΥΡΟΝΗΑ 445 ΤΝΟΛΗΚΑ ΑΠΔΒΗΧΑΝ, 123 ΛΟΓΧ.Ν

17 Chicago Heart Association Detection Project in Industry, E. Navas- Nacher et al. Annals of Internal Medicine 2001; 134:

18 ΟΗ ΚΛΑΗΚΟΗ ΠΑΡΑΓΟΝΣΔ ΚΗΝΓΤΝΟΤ ΔΥΟΤΝ ΗΓΗΑ ΗΥΤ Δ ΟΛΔ ΣΗ ΖΛΗΚΗΔ (ΔΚΣΟ ΥΟΛΖΣΔΡΟΛΖ)

19 ΞΔΚΗΝΖΔ ΣΟ 1985 Δ 4 ΠΟΛΔΗ ΣΧΝ Ζ.Π.Α 5115 ΝΔΟΗ ΔΣΧΝ Ζ ΜΔΛΔΣΖ ΑΚΟΜΑ ΤΝΔΥΗΕΔΣΑΗ

20 Annals of Internal Medicine 2010; 153:

21 Nonoptimal levels of LDL chol. (>100mg/dL), HDL chol. (<60 mg/dl), or triglycerides >150mg/dL were found in 87% of young adults in the study ΜΟΝΟ 8% ΑΣΒΕΣΤΩΣΗ ΣΕ LDL<70 TO 44% ΑΣΒΕΣΤΩΣΗ ΣΕ LDL>160 RR: 1,5 RR: 2,4 RR: 3,3 RR: 5,6

22 Annals of Internal Medicine 2010; 153: ΝΔΟΗ ΔΣΧΝ, ΠΑΡΑΚΟΛΟΤΘΖΖ 20 ΔΣΖ, 7 ΦΟΡΔ ΜΔΣΡΖΖ ΛΗΠΗΓΗΧΝ. ΟΗ ΠΑΘΟΛΟΓΗΚΔ ΣΗΜΔ LDL ΥΟΖΣΔΡΟΛΖ ΣΖΝ ΝΔΑΡΖ ΖΛΗΚΗΑ ΥΔΣΗΕΟΝΣΑΗ ΜΔ ΑΒΔΣΧΖ ΣΑ ΣΔΦΑΝΗΑΗΑ ΚΑΘΧ ΑΤΞΑΝΔΗ Ζ ΖΛΗΚΗΑ. ΔΠΗΖ ΠΑΡΑΣΖΡΖΘΖΚΔ ΜΗΑ ΑΝΑΣΡΟΦΖ ΤΥΔΣΗΖ (ΛΗΓΟΣΔΡΟ ΗΥΤΡΖ) ΜΔ ΣΑ ΔΠΗΠΔΓΑ ΣΖ HDL ΥΟΛΖΣΔΡΟΛΖ. ΜΔΣΑ ΑΠΟ ΠΟΛΤΠΑΡΑΓΟΝΣΗΚΖ ΑΝΑΛΤΖ ΓΔΝ ΠΑΡΑΣΖΡΖΘΖΚΔ ΤΥΔΣΗΖ ΣΗ ΣΗΜΔ ΣΧΝ ΣΡΗΓΛΤΚΔΡΗΓΗΧΝ ΚΑΗ ΑΒΔΣΧΖ ΣΗ ΣΔΦΑΝΗΑΗΔ ΑΡΣΖΡΗΔ. ΗΓΑΝΗΚΑ ΔΠΗΠΔΓΑ ΛΗΠΗΓΗΧΝ ΚΤΡΗΧ LDL ΥΟΛΖΣΔΡΟΛΖ ΣΟΤ ΝΔΟΤ ΤΜΒΑΛΛΟΤΝ ΣΖΝ ΠΡΟΛΖΦΖ ΣΖ.Ν ΓΗΑ ΟΛΖ ΣΖ ΕΧΖ

23 M. Fornage, D Lopez et al. Parental history of MI is associated with a two-fold greater risk of CAC in Caucasians (95% CI = ).

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26 9.6% adults had any CAC men15.0% women 5.1%

27 Early Adult Risk Factor Levels and Subsequent Coronary Artery Calcification The CARDIA Study ΟΗ ΣΗΜΔ ΣΧΝ ΠΑΡΑΓΟΝΣΧΝ ΚΗΝΓΤΝΟΤ ΣΖΝ ΖΛΗΚΗΑ ΔΣΧΝ ΠΡΟΒΛΔΠΟΤΝ ΣΟ ΗΓΗΟ ΚΑΛΑ ΣΖΝ ΑΒΔΣΧΖ ΣΧΝ ΣΔΦΑΝΗΑΗΧΝ ΣΗ ΖΛΗΚΗΔ ΜΔ ΣΟ ΜΔΟ ΟΡΟ ΣΧΝ ΣΗΜΧΝ ΚΑΣΑ ΣΖ 15ΔΣΖ ΠΑΡΑΚΟΛΟΤΘΖΖ (ΔΚΣΟ ΑΠΟ ΣΖΝ ΤΣΟΛΗΚΖ Α.Π) Ζ ΜΔΣΡΖΖ ΣΧΝ ΠΑΡΑΓΟΝΣΧΝ ΚΗΝΓΤΝΟΤ ΣΖΝ ΖΛΗΚΗΑ ΔΣΧΝ ΤΠΔΡΔΥΔΗ ΣΖΝ ΠΡΟΒΛΔΦΖ ΑΒΔΣΧΖ ΣΧΝ ΣΔΦΑΝΗΑΗΧΝ ΣΗ ΖΛΗΚΗΔ ΑΠΟ ΣΗ ΣΡΔΥΟΤΔ ΣΗΜΔ ΣΧΝ ΠΑΡΑΓΟΝΣΧΝ. ΝΔΟΗ ΜΔ ΠΑΡΑΓΟΝΣΔ ΚΗΝΓΤΝΟΤ ΣΖΝ ΖΛΗΚΗΑ 18-30, ΔΥΟΤΝ 2-3 ΦΟΡΔ ΜΔΓΑΛΤΣΔΡΖ ΠΗΘΑΝΟΣΖΣΑ ΝΑ ΔΥΟΤΝ ΑΒΔΣΧΖ ΣΔΦΑΝΗΑΗΧΝ ΑΡΣΖΡΗΧΝ ΣΑ ΔΣΖ. ΔΠΗΖ ΜΔΓΑΛΤΣΔΡΖ ΠΗΘΑΝΟΣΖΣΑ ΓΗΑ ΑΒΔΣΧΖ ΣΔΦΑΝΗΑΗΧΝ ΑΡΣΖΡΗΧΝ ΔΥΟΤΝ ΚΑΗ ΟΗ ΝΔΟΗ ΜΔ ΟΗΚΟΓΔΝΔΗΑΚΟ ΗΣΟΡΗΚΟ ΣΔΦΑΝΗΑΗΑ ΝΟΟΤ ΑΝΔΞΑΡΣΖΣΑ ΑΠΟ ΣΑ ΔΠΗΠΔΓΑ ΣΧΝ ΠΑΡΑΓΟΝΣΧΝ ΚΗΝΓΤΝΟΤ. ΑΤΣΔ ΟΗ ΓΤΟ ΟΜΑΓΔ ΝΔΧΝ ΘΑ ΠΡΔΠΔΗ ΝΑ ΑΠΟΣΔΛΟΤΝ ΣΟΥΟ ΓΗΑ ΔΓΚΑΗΡΖ ΠΡΟΛΖΦΖ, ΓΗΑΣΗ ΑΝ ΠΔΡΗΜΔΝΟΤΜΔ ΣΑ ΟΡΗΑ ΠΟΤ ΟΡΗΕΟΤΝ ΟΗ ΚΑΣΔΤΘΤΝΣΖΡΗΔ ΟΓΖΓΗΔ, Ζ ΑΘΖΡΧΜΑΣΗΚΖ ΠΛΑΚΑ ΘΑ ΔΥΔΗ ΖΓΖ ΥΖΜΑΣΗΣΔΗ ΣΖΝ ΖΛΗΚΗΑ ΣΧΝ ΔΣΧΝ.

28 197 men, 187 women coronary risk factors measured 3 times (mean age 15, 27,33.) Electron beam computed tomography for CAC. Coronary artery calcification 31% in men and 19% in women

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30 ΔΗΓΗΚΖ ΑΝΑΦΟΡΑ ΓΗΑ ΠΡΧΗΜΖ.Ν ΟΗΚΟΓΔΝΖ ΤΠΔΡΥΟΛΖΣΔΡΟΛΑΗΜΗΑ ΔΛΔΓΥΟ ΓΗΑ Lp(a) ΚΑΗ ΟΜΟΚΤΣΔΗΝΖ Δ ΝΔΟΤ ΠΟΤ ΔΥΟΤΝ ΤΓΓΔΝΔΗ ΜΔ ΠΡΧΗΜΖ.Ν.

31 SERUM CHOLESTEROL IN YOUNG MEN AND SUBSEQUENT CARDIOVASCULAR DISEASE KLAG M.J et al. N ENGL J MED Feb 4;328(5): ΦΟΗΣΖΣΔ ΗΑΣΡΗΚΖ (Johns Hopkins University) 22 ΔΣΖ ΜΔΖ ΖΛΗΚΗΑ 30 ΔΣΖ ΜΔΖ ΠΑΡΑΚΟΛΟΤΘΖΖ Ζ ΑΤΞΖΖ ΣΖ ΥΟΛΖΣΔΡΗΝΖ ΚΑΣΑ 36mg/dl ΑΤΞΑΝΔΗ ΣΟΝ ΚΗΝΓΤΝΟ ΓΗΑ.Ν (relative risk: 2.01, 95% CI: 1.59 to 2.53)

32 ΟΤΣΔ ΚΑΝ ΟΗ ΜΗΟΗ ΑΠΟ ΣΟΤ ΝΔΟΤ ΓΔΝ ΓΝΧΡΗΕΟΤΝ ΣΑ ΔΠΗΠΔΓΑ ΣΧΝ ΛΗΠΗΓΗΧΝ ΣΟΤ Prevalence of Coronary Heart Disease Risk Factors and Screening for High Cholesterol Levels Among Young Adults, United States, (NHANES) E Kuklina et al. Ann Fam Med 2010;8: young adults men aged years and women aged years. About 55.2% of young adults had at least one cardiovascular disease risk factor and 17.9% had two. (risk factors: smoking, hypertension, obesity, or family history of early CHD). In our study, the overall screening rate in this population was less than 50%.

33 0,5 0,45 0,4 0,35 0,3 0,25 0,2 0,15 0,1 0,05 0 ΑΓΟΡΙΑ 32,60% ΜΑΘΖΣΔ ΛΤΚΔΗΟΤ ΚΟΡΙΣΙΑ 26,70%

34 Factors associated with adolescent cigarette smoking in Greece: Results from a cross sectional study (GYTS Study) George Rachiotis et al. BMC Public Health 2008, 8:313 0,6 0,5 48,20% 0,4 Ν: μαθθτζσ 0,3 0,2 0,1 0 9,40% ετϊν ετϊν

35 Ζ ΔΠΗΠΣΧΖ ΣΖ ΤΠΔΡΣΑΖ ΣΖΝ ΜΔΛΔΣΖ ΑΣΣΗΚΖ ATTICA STUDY PANAGIOTAKOS D, PITSAVOS C et al, J Hypertens 2004

36 Ζ ΔΠΗΠΣΧΖ ΣΟΤ.ΓΗΑΒΖΣΖ Δ ΓΔΝΗΚΟ ΠΛΖΘΤΜΟ ΣΖΝ ΔΛΛΑΓΑ 25,0 22,3 21,6 20,0 ΔΛ.Η.ΚΑΡ. (n= , ) ΔΛ.Η.ΚΑΡ. (n= , ) 16,2 16,4 18,5 18,5 P< ,0 10,0 10,1 11,2 12,5 11,5 Men Women 6,7 7,4 5,0 3,0 2,4 4,4 5 0,0 <40 ζτθ ζτθ ζτθ ζτθ ζτθ ζτθ 90 ζτθ Overall Hellenic Heart Foundation 2007 (unpublished data)

37 ΔΠΗΠΣΧΖ ΠΑΥΤΑΡΚΗΑ Δ ΓΔΝΗΚΟ ΠΛΖΘΤΜΟ ΣΖΝ ΔΛΛΑΓΑ (ΒΜΗ > 30 kg/m 2 ) Γενικόσ τφποσ 10 Γενικόσ τφποσ 23,1 Γενικόσ τφποσ 22,6 Γενικόσ τφποσ Γενικόσ τφποσ 22,2 21,5 Γενικόσ τφποσ 21,3 ΔΛ.Η.ΚΑΡ. Γενικόσ τφποσ ΔΛ.Η.ΚΑΡ. 19,4 Γενικόσ τφποσ 18,9 ΔΛ.Η.ΚΑΡ. Γενικόσ τφποσ Γενικόσ τφποσ (n= , ) (n= , ) (n= , ) Γενικόσ τφποσ 15,2 Γενικόσ τφποσ 10,3 10,4 16,4 Males (%) Males (%) Females (%) 5 4,9 0 <30 ζτθ ζτθ ζτθ ζτθ ζτθ 70 ζτθ <30 ζτθ ζτθ ζτθ ζτθ ζτθ 70 ζτθ Hellenic Heart Foundation 2007 (unpublished data)

38 Eleven-year prevalence trends of obesity in Greek children: first evidence that prevalence of obesity is leveling off Ν: Obesity (2010) 18 1, K. Tambalis, D. Panagiotakos, S. Kavouras, A. Kallistratos, I. Moraiti, S. Douvis, P. Toutouzas L. Sidossis

39 Eleven-year prevalence trends of obesity in Greek children: first evidence that prevalence of obesity is leveling off Ν: Obesity (2010) 18 1, K. Tambalis, D. Panagiotakos, S. Kavouras, A. Kallistratos, I. Moraiti, S. Douvis, P. Toutouzas L. Sidossis

40 ΓΗΑΣΗ ΣΟΟ ΔΝΓΗΑΦΔΡΟΝ ΓΗΑ ΣΖΝ ΠΑΗΓΗΚΖ ΠΑΥΤΑΡΚΗΑ; «80% ηωλ παρύζαξθωλ εθήβωλ ζα γίλνπλ παρύζαξθνη ελήιηθεο» Dietz WH. Critical periods in childhood for the development of obesity. Am J Clin Nutr. 1994;59: «Σν απμεκέλν ζωκαηηθό βάξνο θαηά ηελ παηδηθή δωή πξνβιέπεη ηελ εκθάληζε Τπεξιηπηδαηκίαο,Τπέξηαζεο θαη Γ θαηά ηελ ελήιηθν δωή» Bhargava SK, et al. Relation of serial changes in childhood body-mass index to impaired glucose tolerance in young adulthood. N Engl J Med. 2004;350: «Ζ παρπζαξθία είλαη ν πην ζεκαληηθόο παξάγνληαο θηλδύλνπ γηα θαξδηαγγεηαθά λνζήκαηα θαηά ηελ εθεβεία» Must A. Does overweight in childhood have an impact on adult health? Nutr Rev. 2003;61:

41 Aims, methods and preliminary findings of the Physical Activity, Nutrition and Allergies in Children Examined in Athens (PANACEA) epidemiological study Kostas N Priftis, Demosthenes B Panagiotakos, et al, BMC Public Health. 2007; 7: 140. During schoolchildren (323 m 377 f), years

42 11% OF AMI PTS <50 YEARS OLD (HELIOS STUDY) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 94% 93% 73% 67% 81% 72% 29% 62% PTS<50YEARS OLD PTS>50 YEARS OLD 51% 50% 14% 33% MALE SMOKING ΒΜΙ>25 HYPERTENSION CHOLESTEROL D.M

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44 We included 10,551 male participants of the CHA in Chicago Heart Association Study who were aged 18 to 39 years and free of baseline CHD and diabetes at enrollment from 1967 to Risk of CHD was estimated using both FRS and ATP III online risk estimator for each individual. In conclusion, both the FRS and the ATP III online risk estimator were able to order risk. The FRS was unable to classify the young adults in this cohort as anything other than low risk even in the face of a substantial risk factor burden estimates accurately among young adult men. However, neither strategy was able to identify high risk individuals (i.e. >20% absolute risk in 10 years) younger than 30 years despite substantial risk factor burden. Future clinical guidelines should consider alternative strategies to estimate and communicate CVD risk to the young adult population.

45 PDAY Score * -15 to 34 yo - Athero lesions at autopsy -CA: Odds by 18% per point McMahan AIM2005 Pathobiological Determinants of Atherosclerosis in Youth

46 Pathobiological Determinants of Atherosclerosis in Youth (PDAY study)

47 Estimated probability of advanced atherosclerotic lesions in the coronary arteries by PDAY risk score computed from modifiable risk factors and 5-year age group for men (left) and women (right). McGill H C et al. Circulation 2008;117: Copyright American Heart Association

48 Prediction of Coronary Artery Calcium in Young Adults Using PDAY Risk Score. The CARDIA Study. Samuel S. Gidding, MD; C. Alex McMahan, PhD; Henry C. McGill, MD et al. PDAY SCORE Arch Intern Med. 2006;166: The risk score computed from risk factors measured 10 to 15 years before the assessment of CAC performed better than the risk score computed from risk factors at the time of CAC assessment. If the risk score increased between year 0 and year 15, the likelihood of developing CAC increased; if the risk score decreased, the likelihood of developing CAC decreased. The PDAY risk score and a revised PDAY risk score that included family history of cardiovascular disease and a greater differential between the sexes performed better than the Framingham risk score.

49 ΤΓΚΡΗΖ PDAY SCORE KAI FRS ηην Framingham Heart Study ζηον πληθσζμό μελέηης δεν σπήρταν < 30 εηών. ηο Framingham risk score σπάρτοσν αρνηηικές ηιμές για ηλικίες <30 εηών. Σο PDAY risk score προβλέπει αθηρογένεζη. Tο Framingham risk score προβλέπει κίνδσνο για κλινικά ζσμβάμαηα από ζηεθανιαία νόζο.

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53 ΛΗΓΟΣΔ ΟΗ ΚΑΣΔΤΘΤΝΣΖΡΗΔ ΟΓΖΓΗΔ ΓΗΑ ΠΡΟΛΖΦΖ ΣΔΦΑΝΗΑΗΑ ΝΟΟΤ ΣΟΤ ΝΔΟΤ ΜΔΣΡΖΖ ΥΟΛΖΣΔΡΟΛΖ Δ ΟΛΟΤ ΣΑ 20 ΔΣΖ ΚΑΗ ΜΔΣΑ ΔΛΔΓΥΟ ΑΝΑ ΠΔΝΣΑΔΣΗΑ. (National Cholesterol Education Program, ΑΗΑ 2010) ΔΛΔΓΥΟ ΓΗΑ ΤΠΔΡΣΑΖ Δ ΟΛΟΤ ΣΟΤ ΔΝΖΛΗΚΟΤ >18 ΔΣΧΝ ΚΑΗ ΜΔΣΑ ΑΝΑ ΓΗΔΣΗΑ. ( ΑΖΑ 2010, JNC 6, Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure) ΑΚΡΟΓΧΝΗΑΗΟΗ ΛΗΘΟΗ ΓΗΑ ΠΡΟΛΖΦΖ ΣΧΝ ΠΑΡΑΓΟΝΣΧΝ ΚΗΝΓΤΝΟΤ ΑΘΖΡΧΜΑΣΗΚΖ ΝΟΟΤ ΣΖΝ ΝΔΑΡΖ ΖΛΗΚΗΑ ΔΗΝΑΗ Ζ ΓΗΑΗΣΑ ΚΑΗ Ζ ΦΤΗΚΖ ΓΡΑΣΖΡΗΟΣΖΣΑ. (ΑΗΑ, NCEP, AAP 2008)

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55 Age in Years Ζ ΑΘΖΡΟΚΛΖΡΤΝΖ ΔΗΝΑΗ ΜΗΑ ΔΞΔΛΗΟΜΔΝΖ ΝΟΟ Myocardial infarct Cerebral infarct Gangrene of extremities Abdominal Aortic aneurysm Clinical horizon ΟΟ ΝΧΡΗΣΔΡΑ ΣΟΟ ΚΑΛΤΣΔΡΑ Calcification Complication lesion hemorrhage, ulceration, thrombosis Fibrous plaque Fatty steaks ΠΡΔΠΔΗ ΝΑ ΣΟΥΔΤΟΤΜΔ ΣΟΤ ΝΔΟΤ

56 ΤΜΠΔΡΑΜΑΣΑ 1 ΣΟΟ ΟΗ ΑΤΣΟΦΗΔ ΟΟ ΚΑΗ ΟΗ ΜΔΛΔΣΔ ΠΟΤ ΠΡΟΑΝΑΦΔΡΘΖΚΑΝ ΓΔΗΥΝΟΤΝ ΣΖΝ ΠΑΡΟΤΗΑ ΛΗΠΧΓΧΝ ΓΡΑΜΜΧΔΧΝ Ζ ΚΑΗ ΑΘΖΡΧΜΑΣΗΚΧΝ ΠΛΑΚΧΝ ΣΑ ΣΔΦΑΝΗΑΗΑ ΑΓΓΔΗΑ ΣΧΝ ΝΔΧΝ. Ο ΔΛΔΓΥΟ ΣΧΝ ΚΛΑΗΚΧΝ ΠΑΡΑΓΟΝΣΧΝ ΚΗΝΓΤΝΟΤ ΣΖΝ ΔΦΖΒΔΗΑ ΚΑΗ ΔΝΖΛΗΚΗΧΖ ΘΑ ΜΔΗΧΔΗ ΖΜΑΝΣΗΚΑ ΣΖΝ ΔΜΦΑΝΗΖ ΣΖ.Ν ΣΟΤ ΜΔΖΛΗΚΔ ΚΑΗ ΖΛΗΚΗΧΝΔΝΟΤ. Ζ ΟΗΚΟΓΔΝΔΗΑ, ΣΟ ΥΟΛΔΗΟ ΚΑΗ Ζ ΚΟΗΝΧΝΗΑ ΘΑ ΠΡΔΠΔΗ ΝΑ ΚΑΘΟΓΖΓΟΤΝ Δ ΤΓΗΔΗΝΟ ΣΡΟΠΟ ΕΧΖ (ΧΣΖ ΓΗΑΣΡΟΦΖ, ΑΚΖΖ ΚΑΗ ΑΠΟΦΤΓΖ ΚΑΠΝΟΤ ΚΑΗ ΠΑΥΤΑΡΚΗΑ). ΟΗ ΓΗΑΣΡΟΗ ΘΑ ΠΡΔΠΔΗ ΝΑ ΔΤΑΗΘΖΣΟΠΟΗΖΘΟΤΝ: ΣΖΝ ΑΝΗΥΝΔΤΖ ΝΔΧΝ ΑΝΘΡΧΠΧΝ ΜΔ ΚΛΑΗΚΟΤ ΠΑΡΑΓΟΝΣΔ ΚΗΝΓΤΝΟΤ ΓΗΑ.Ν. ΚΑΗ ΣΟΝ ΔΛΔΓΥΟ ΑΤΣΧΝ ΣΧΝ ΠΑΡΑΓΟΝΣΧΝ. ΟΗ ΚΑΡΓΗΟΛΟΓΗΚΔ ΔΣΑΗΡΔΗΔ ΘΑ ΠΡΔΠΔΗ ΝΑ ΣΡΟΠΟΠΟΗΖΟΤΝ ΣΑ ΠΡΟΓΡΑΜΜΑΣΑ ΠΡΟΛΖΦΖ.Ν. ΧΣΔ ΝΑ ΜΖΝ ΔΣΗΑΕΟΝΣΑΗ ΜΟΝΟ ΣΟΤ ΔΝΖΛΗΚΔ, ΑΛΛΑ ΝΑ ΣΟΥΔΤΟΤΝ ΚΑΗ ΣΟΤ ΝΔΟΤ.

57 ΤΜΠΔΡΑΜΑΣΑ 2 ΠΡΔΠΔΗ ΝΑ ΣΟΥΔΤΟΤΜΔ Δ ΜΗΑ ΚΟΗΝΧΝΗΑ ΠΟΤ ΟΗ ΝΔΟΗ ΝΑ ΔΝΖΛΗΚΗΧΝΟΝΣΑΗ ΜΔ ΥΑΜΖΛΟ ΚΗΝΓΤΝΟ ΓΗΑ.Ν, ΚΑΗ ΝΑ ΓΗΑΣΖΡΟΤΝ ΑΤΣΟ ΣΟ ΥΑΜΖΛΟ ΚΗΝΓΤΝΟ ΓΗΑ ΣΖΝ ΤΠΟΛΟΗΠΖ ΕΧΖ ΣΟΤ. ΟΗ ΑΛΛΑΓΔ ΣΖΝ ΚΟΤΛΣΟΤΡΑ ΚΑΗ ΣΖΝ ΚΟΗΝΧΝΗΚΖ ΤΜΠΔΡΗΦΟΡΑ ΓΗΑ ΝΑ ΔΠΗΣΔΤΥΘΔΗ ΑΤΣΟ Ο ΣΟΥΟ ΓΔΝ ΘΑ ΔΗΝΑΗ ΔΤΚΟΛΔ, ΟΤΣΔ ΘΑ ΤΜΒΟΤΝ ΑΜΔΧ. ΟΜΧ ΔΗΝΑΗ ΧΡΑ ΝΑ ΞΔΚΗΝΖΟΤΝ!!!

58 ΔΤΥΑΡΗΣΧ ΓΗΑ ΣΖΝ ΠΡΟΟΥΖ Α! Ο ΜΤΡΟΒΟΛΟ ΚΑΜΠΟ ΣΗ ΧΙΟΤ

59 ΤΕΛΟΣ

60 Cholesterol and Mortality 30 Years of Follow-up From the Framingham Study Anderson K, Castelli W, Levy D, JAMA 1987;257: ABSTRACT: From 1951 to 1955 serum cholesterol levels were measured in 1959 men and 2415 women aged between 31 and 65 years who were free of cardiovascular disease (CVD) and cancer. Under age 40 years, cholesterol levels are directly related with 30-year overall and CVD mortality; overall death increases 5% and CVD death 9% for each 10 mg/dl. After age 40 years there is no increased overall mortality with either high or low serum cholesterol levels. There is a direct association between falling cholesterol levels over the first 14 years and mortality over the following 18 years (11% overall and 14% CVD death rate increase per 1mg/dL per year drop in cholesterol levels). Under age 40 years these data suggest that having a very low cholesterol level improves longevity. After age 40 years the association of mortality with cholesterol values is confounded by people whose cholesterol levels are falling perhaps due to diseases predisposing to death.

61 PREVALENCE OF SMOKING IN EUROPE (2003)

62 ΠΟΟΣΟ ΜΔΣΑΒΟΛΖ ΣΟΤ ΘΑΝΑΣΟΤ ΑΠΟ.Ν (WHO)

63 PDAY risk score predicts advanced coronary artery atherosclerosis in middle-aged persons as well as youth. Mc Mahan C et al. PDAY Research Group, Αtherosclerosis 2007 Feb;190(2): Abstract A risk score formula to estimate the probability of advanced atherosclerosis using coronary heart disease (CHD) risk factors was developed for persons years of age by the Pathobiological Determinants of Atherosclerosis in Youth (PDAY) study. We applied the PDAY risk score to autopsied individuals from the Community Pathology Study (CPS), a different population that included middle-aged as well as young subjects. The PDAY risk score was associated with extent of raised lesions in the coronary arteries of CPS cases years of age. The PDAY risk score computed from only the modifiable risk factors was associated with extent of raised lesions in the coronary arteries of subjects years of age. The association of the PDAY risk score with lesions in year old CPS subjects validates the PDAY risk score. The associations in both younger (15-34 years) and older (35-54 years) subjects suggest a seamless progression of the effects of the modifiable risk factors on atherosclerosis from 15 to 54 years of age. These results support the proposal that early control of risk factors is likely to prevent or delay the onset of CHD.

64 Ζ ΔΠΗΠΣΧΖ ΣΖ ΤΠΔΡΣΑΖ Δ ΓΔΝΗΚΟ ΠΛΖΘΤΜΟ ΣΖΝ ΔΛΛΑΓΑ Γενικόσ τφποσ Γενικόσ τφποσ Γενικόσ τφποσ ΔΛ.Η.ΚΑΡ. (n= , ) Γενικόσ τφποσ Γενικόσ τφποσ Γενικόσ τφποσ Γενικόσ τφποσ Γενικόσ τφποσ Γενικόσ Γενικόσ τφποσ τφποσ Γενικόσ τφποσ Γενικόσ τφποσ Γενικόσ τφποσ Γενικόσ τφποσ Γενικόσ τφποσ Γενικόσ Γενικόσ τφποσ τφποσ Γενικόσ τφποσ Males (%) Females (%) Γενικόσ τφποσ <30 ζτθ ζτθ ζτθ ζτθ ζτθ 70 ζτθ Andrikopoulos G, et al. ESC 2007

65 An elevated lipoprotein(a) [Lp(a)] level is an independent risk factor of premature CAD [21] and is particularly a significant risk factor for premature atherothrombosis and cardiovascular events. Measurement of Lp(a) is more useful for young individuals with a personal or family history of premature vascular disease and repeat coronary interventions. The 2010 ACCF/AHA guideline for assessment of cardiovascular risk in asymptomatic adults states that, in asymptomatic intermediate-risk adults, lipoproteinassociated phospholipase A2 might be reasonable for cardiovascular risk assessment. [3] Lp(a) may be used to identify people at increased cardiovascular risk, but as of yet, there have been no studies on Lp(a) lowering because of the lack of available agents that are effective in reducing this value. Therefore, low-density lipoprotein (LDL) lowering is probably the best strategy in people with elevated Lp(a) levels. [22]

66 Established Risk Factors for CHD in Adults Wilson Circulation 1998

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68 Guidelines for risk assessment call for cholesterol to be measured beginning at age 20, and for blood pressure to be measured every two years in adulthood. Blood glucose should be measured at least every 3 years beginning at age 45, and earlier for persons at risk. "As this study illustrates, we are learning more and more about the beginnings of heart disease and how to prevent it," said Catherine Loria, PhD., lead study author and nutritional epidemiologist with NHLBI. "Young men and women should work with their doctors to learn about their risk, and then do everything they can to reduce it, such as eating a healthy diet and being physically active," she added. To help prevent heart disease, individuals should avoid smoking, seek to achieve and maintain a healthy weight, choose a diet that is low in sodium, saturated fat, trans fat and cholesterol, and get at least 30 minutes of moderate-intensity physical activity on most, or preferably all, days of the week.

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70 Lipoprotein(a) has been shown to be an independent risk factor for coronary heart disease in middle-aged, hyperlipidemic white men, although it may not be a risk factor in white men with normal lipid levels (29). To our knowledge, no prospective studies of other racial groups or women have been published. In our study, lipoprotein(a) was not associated with increased risk for coronary artery calcification in male or female young adults Recently, a number of studies have shown that plasma concentration of homocysteine, an amino acid that results from the demethylation of methionine, is higher in paiients with cerebrovascular, peripheral arterial and coronary heart disease than in control subjects ( ). However, in our study, no sign&ant difference was seen in this newly recognixed risk factor in subjects with and without coronary artery calcification. This finding may in part relate ro the lower mean age of our study participants than those in the cited studies

71 The writing committee felt that it is reasonable to advocate global risk score measures coincident with guideline-supported measurements of blood pressure or cholesterol beginning at age 20 and then every 5 years thereafter (27). The writing committee also acknowledged that some investigators advocate a shift in the risk assessment focus to lifetime risk of CHD, but to date, evidence is sparse on how best to incorporate estimates of lifetime risk into clinical management (11). Another approach to the long-term risk estimation problem in younger adults was recently presented by the Framingham Study investigators as the 30-Year Risk of Cardiovascular Disease

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74 Early cholesterol predicts later coronary calcium August 2, 2010 Reed Miller San Francisco, CA - A new prospective cohort study suggests younger people will pay for high cholesterol in the present with coronary calcium in the future, according to results of a study published in the August 3, 2010 issue of the Annals of Internal Medicine [1]. In the latest study from the ongoing Coronary Artery Risk Development in Young Adults (CARDIA) trial, Dr Mark Pletcher (University of California, San Francisco) and colleagues measured LDL cholesterol, HDL cholesterol, triglycerides, and coronary calcium in 3258 subjects age 18 to 20 in 1985 and They estimated time-averaged cumulative exposures to lipids between age 20 and 35 with repeated serum lipid measurements over 20 years and then related these data to coronary calcium scores acquired with computed tomography at years 15 and 20. Nonoptimal levels of LDL cholesterol (>100 mg/dl), HDL cholesterol (<60 mg/dl), or triglycerides >150 mg/dl were found in 87% of young adults in the study. Coronary calcium prevalence 20 years later was 8% in participants who maintained optimal LDL levels <70 mg/dl and 44% in participants with LDL-cholesterol levels of >160 mg/dl (p<0.001). The same association was found in all races and genders. The odds of finding coronary calcium increased as LDL increased. For example, compared with people with LDL levels less than 70 mg/dl, the odds ratio for coronary calcium later in life for patients with 70 to 99 mg/dl in their early adulthood was 1.5. For people with LDL of 100 to 129 mg/dl, the odds ratio was 2.4, and for people with LDL of 160 mg/dl or greater, the odds ratio was 5.6. The results show that nonoptimal LDL-cholesterol levels during young adulthood are linked to coronary calcification down the road and that accounting for later-life lipid exposure does not explain the association of young adult LDL-cholesterol levels with later calcification. After the authors adjusted their analysis for "the potentially obscuring influences" of subjects' medication and clinically abnormal levels of other lipids, they observed an inverse association with HDL-cholesterol levels but no association with triglyceride levels. Pletcher et al acknowledge that coronary calcium is a "subclinical end point," because the cohort is still too young to have enough MIs or deaths to study the connection between early lipid levels and those clinical outcomes. However, they point out that coronary calcium has been shown to be a strong independent predictor of CHD events and that the absence of coronary calcium is a strongly protective factor. The authors recall previous studies that have found associations between lipid levels and atherosclerosis in children and young adults, demonstrated by autopsy, carotid intima-media thickness, and coronary calcium. But this CARDIA analysis is the first with adequate sample size, repeated measurements of the three major lipids, and sufficient follow-up to isolate the link between lipid levels during young adulthood with atherosclerosis during middle age while controlling for confounders, they claim. "Our results suggest that atherosclerotic changes begin during young adulthood as a result of commonly observed nonoptimal lipid levels, that these changes persist into middle age, and that maintaining optimal levels of lipids particularly LDL cholesterol throughout young adulthood could provide substantial benefits in terms of lifetime coronary heart disease prevention," Pletcher et al conclude. "These findings reinforce the importance of a heart-healthy diet, exercise, and maintenance of normal weight beginning in young adulthood." "What we show here is that it matters what your cholesterol level is during young adulthood, and you should be thinking about it and trying to optimize it during young adulthood so that you have less built-up atherosclerosis later in life, and that will stand you in good stead for reducing your heart-attack risk later in life," Pletcher told heartwire. "We're not directly testing the hypothesis that modifying cholesterol with diet and exercise during young adulthood makes a difference later in life. But there's so much evidence that cholesterol really is a cause of heart disease that we think that it's reasonable that the same thing is going on here that it's a treatable cause of disease that can be avoided." He cautioned that the study does not address whether medication to lower cholesterol early in life will be beneficial, but Pletcher says these data support the AHA recommendation to begin cholesterol tests as early as 20. "I'm a general believer in the tenet that if you

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76 ost powerful argument for rethinking the American childs diet comes from the Bogalusa Heart Stu been described as the longest and most detailed study of children in the world. In terms of heart se prevention, this study is as crucial to children as the famous Framingham Heart Study is to adults uriously, the Bogalusa Heart Study has received little attention from pediatricians or the, though results have been published in major medical journals over the last two decades. performed autopsies on 204 young persons 2 to 39 years of age, who had died from various causes on antemortem risk factors were available for 93 of these persons, who were the focus of this stu factors with the extent of atherosclerosis in the aorta and coronary arteries. extent of fatty streaks and fibrous plaques in the aorta and coronary arteries increased with age. T een fatty streaks and fibrous plaques was much stronger in the coronary arteries (r=0.60, P< , P=0.03). Among the cardiovascular risk factors, body-mass index, systolic and diastolic blood p entrations of total cholesterol, triglycerides, low-density lipoprotein cholesterol, and high-density esterol, as a group, were strongly associated with the extent of lesions in the aorta and coronary ar elation [a measure of the association between groups of variables]: r=0.70; P<0.001). In addition, c eased the percentage of the intimal surface involved with fibrous plaques in the aorta (1.22 percen ent in nonsmokers, P=0.02) and fatty streaks in the coronary vessels (8.27 percent vs percent ultiple risk factors on the extent of atherosclerosis was quite evident. Subjects with 0, 1, 2, and 3 o, respectively, 19.1 percent, 30.3 percent, 37.9 percent, and 35.0 percent of the intimal surface cov aks in the aorta (P for trend=0.01). The comparable figures for the coronary arteries were 1.3 perce ent, and 11.0 percent, respectively, for fatty streaks (P for trend=0.01) and 0.6 percent, 0.7 percent percent for collagenous fibrous plaques (P for trend=0.003). se findings indicate that as the number of cardiovascular risk factors increases, so does the severity

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81 We came up with four questions: What are the risk factors in children and how to define abnormal ones? What is the interrelation of risk factors? Do risk factors persist over time and predict adult levels? And what are the genetic and metabolic characteristics of young individuals with high or low levels? (12,13)

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84 ids, and reduce sodium and calories to reduce prevalence of esity.16,17 Increased physical activity and improved cardiovascular ness may both blunt the obesity epidemic and crease cardiovascular disease risk. dividualized nonpharmacological therapy without changing e food processing in a common source epidemic, such as herosclerosis, is unlikely to be successful. Therefore, a major odification of food processing and distribution and consumer ucation and possibly regulation would probably have the ggest effect but remains extremely difficult to implement.18 e could hope for a pill that will prevent the development the final thrombosis or ruptured plaque.19 Such an approach unlikely to be of substantial benefit alone in ducing the risk of CHD unless the extent of atherosclerotic sease is also substantially reduced by the pharmacological d nonpharmacological approaches. e have come full circle from the recognition that CHD is an ample of a common source epidemic to try and classify dividuals arbitrarily into high, intermediate, and low shortterm sk to finally recognizing the importance of long-term risk CHD and the need to treat CHD as a common source idemic.18 We hope not to spend the next 20 years developing w risk assessment tools and a never-ending list of risk ctors.

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87 Arterioscler Thromb Vasc Biol Oct;30(10): Epub 2010 Jul 8. Coffee, decaffeinated coffee, caffeine, and tea consumption in young adulthood and atherosclerosis later in life: the CARDIA study. Reis JP, Loria CM, Steffen LM, Zhou X, van Horn L, Siscovick DS, Jacobs DR Jr, Carr JJ. Source Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, Md 20892, USA. Abstract OBJECTIVE: To determine the association of coffee, decaffeinated coffee, caffeine, and tea consumption in young adulthood with the presence and progression of coronary artery calcified (CAC) plaque and carotid intima-media thickness later in life. METHODS AND RESULTS: The Coronary Artery Risk Development in Young Adults (CARDIA) Study is a cohort of 5115 white and black adults who were aged 18 to 30 years when they completed a baseline clinic examination from 1985 to Subsequent examinations were conducted 2, 5, 7, 10, 15, and 20 years later. After multivariable adjustment, no association was observed between average coffee, decaffeinated coffee, or caffeine consumption (years 0 and 7) and presence of CAC (score, >0 Agatston units at year 15 or 20), CAC progression (incident CAC at year 20 or increase in CAC score by 20 Agatston units), or high carotid intima-media thickness (>80th percentile, year 20). However, tea consumption displayed a nonsignificant trend for an inverse association with CAC (P=0.08 for trend) and an inverse association with CAC progression (P=0.04 for trend) but no association with high carotid intima-media thickness (P>0.20 for trend). Stratification of the coffee analyses by sex, race, or smoking yielded similar nonsignificant patterns. CONCLUSIONS: We observed no substantial association between coffee or caffeine intake and coronary and carotid atherosclerosis. However, our results suggested an inverse association between tea and CAC but not carotid atherosclerosis

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91 Approaches to CVD prevention Lipid modification Glucose lowering Optimal CV risk reduction Lifestyle intervention BP lowering

92 Coronary fatty steaks begin to form in adolescence Most persons have coronary fatty streaks by the age years.

93 In the PDAY study, the association of serum lipoprotein levels with atherosclerotic lesions in young persons years of age supports the view that control the hyperlipoproteinemia will retard the progression of atherosclerosis in the young.

94 There is strong evidence for the effects of smoking on atherosclerosis in this young age group. The association of a hypertensive index to clinically significant raised arterial lesions is also well established in this young age group, years of age. Elevated glycohemoglobin levels and obesity are associated with accelerated atherosclerosis in the third and fourth decades of life.

95 Control Programs to prevent coronary heart disease should be directed toward individuals in the twenties and thirties for maximum benefits Early detection and control of hypercholesterolemia hypertension, hyperglycemia and obesity in young persons should reduce the risk of atherosclerotic disease later in life. Dietary and other habits that retard atherosclerosis should be established in childhood.

96 BENEFITS OF REGULAR PHYSICAL ACTIVITY Builds Healthy Bones and Muscles Builds Lean Muscle and Reduces Fat Reduces Risk of Heart Disease, Diabetes, Cancer, Hypertension, Oste oporosis, etc Reduces Stress and Depression Improves Fitness & Quality of Life

97 A.H.A. LABELS PHYSICAL INACTIVITY AS A FOURTH RISK FACTOR FOR CORONARY HEART DISEASE New York, July 1, The American Heart Association today labeled physical inactivity, or lack of exercise, as a fourth risk factor for coronary heart disease along with smoking, high blood pressure, and high cholesterol levels. Regular physical activity plays a significant role in preventing heart and blood vessel disease and there is a relationship between physical inactivity and cardiovascular mortality.

98 WHY CHILDREN NEED HEALTH-RELATED PHYSICAL EDUCATION Quality physical education can: reduce the risk of heart disease improve fitness regulate weight promote active lifestyles & health reduce stress & depression increase self-esteem & confidence develop motor skills improve goal setting & self-discipline

99 Why Target Youth? % of children, aged 5-10, with 1 or more adverse CVD risk factor levels: 27.1% % of children, aged 5-10, with 2 or more adverse CVD risk factor levels: 6.9% Source: Freedman DS et al. Pediatrics 1999;103:

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101 Why Target Youth? Risk factor trends are going in the wrong direction Atherosclerosis is present in late adolescence

102 Why Target Youth? The younger people are when they start using tobacco, the more likely they are to become dependent on nicotine 25% of high school students smoked a whole cigarette before age 13* Physical activity and dietary patterns may be established during childhood and adolescence *CDC, National Youth Risk Behavior Survey, 1997

103 Why Target Youth? 80% of adult smokers started smoking before they finished high school Source: U.S. DHHS. Surgeon General s Report: Preventing Tobacco Use Among Young People, 1994

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106 Background In an attempt to evaluate the levels of several cardiovascular risk factors in Greece we conducted a population-based health and nutrition survey, the "ATTICA study". In this work we present the design and the methodology of the study, as well as the status of various baseline characteristics of the participants. Methods From May 2001 to December 2002 we randomly enrolled 1514 adult men and 1528 adult women, stratified by age gender (census 2000), from the greater area of Athens. More than 300 demographic, lifestyle, behavioral, dietary, clinical and biochemical variables have been recorded. Results Regarding the frequency of the classical cardiovascular risk factors we observed that 51% of men and 39% of women reported smokers (p < 0.05), 37% of men and 25% of women were defined as hypertensives (p < 0.05), 46% of men and 40% of women had total serum cholesterol levels above 200 mg/dl (p < 0.05) and 8% of men and 6% of women had history of diabetes mellitus. Moreover, 20% of men and 15% of women were obese (p < 0.05), while men were more physically active as compared to women (42% vs. 39%, p < 0.05). 19% of men and 38% of women had mild to severe depressive symptoms (p < 0.01). Finally, 72 men (5%) and 45 (3%) women reported history of coronary heart disease at entry evaluation. Conclusions The prevalence of the common cardiovascular risk factors in our population seems high. As a consequence a considerable proportion of Greek adults are at "high-risk" for future cardiovascular events.

107 φμφωνα με ςτοιχεία τησ Eurostat (2007), το ποςοςτό των υπέρβαρων με ΒΜΙ>27 κατά ηλικία προκφπτουν τα εξήσ: Στισ θλικίεσ ετϊν: Η Ελλάδα παρουςιάηει ςτουσ μεν άνδρεσ το δεφτερο υψθλότερο ποςοςτό υπζρβαρων (30%) μετά τθ Γερμανία, ενϊ ςτισ γυναίκεσ ζνα ποςοςτό 13% που βρίςκεται ςτα μζςα ευρωπαϊκά επίπεδα. Στισ θλικίεσ: ετϊν: Η Ελλάδα παρουςιάηει ςτουσ μεν άνδρεσ το υψθλότερο ποςοςτό υπζρβαρων (69,6%), ενϊ ςτισ γυναίκεσ το τρίτο υψθλότερο ποςοςτό (41,9%).

108 Prediction of Coronary Artery Calcium in Young Adults Using the Pathobiological Determinants of Atherosclerosis in Youth (PDAY) Risk Score The CARDIA Study Samuel S. Gidding, MD; C. Alex McMahan, PhD; Henry C. McGill, MD; Laura A. Colangelo, MS; Pamela J. Schreiner, PhD; O. Dale Williams, PhD; Kiang Liu, PhD Arch Intern Med. 2006;166: Background Using data from autopsied young people aged 15 to 34 years, the Pathobiological Determinants of Atherosclerosis in Youth (PDAY) study developed a risk score based on age, sex, smoking status, high-density lipoprotein and non high-density lipoprotein cholesterol levels, and the presence of obesity, hyperglycemia, and hypertension to predict advanced coronary artery atherosclerosis. Methods The Coronary Artery Risk Development in Young Adults (CARDIA) study assessed coronary artery calcium (CAC) by computed tomography in young adults participating in the 15-year examination. The PDAY risk score was calculated from risk factors measured at the CARDIA examinations at years 0, 5, 10, and 15. Results Odds ratios for amount of CAC (6 ordinal categories) for a 1-point increase in risk score computed from the modifiable risk factors ranged from 1.10 to 1.16 (all statistically significant). Odds ratios for presence of any amount of CAC ranged from 1.09 to 1.15 (all statistically significant), with the highest odds ratio for the risk score at year 0. An increase in risk score between years 0 and 15 increased the odds of CAC, and a decrease in risk score decreased the odds of CAC. A positive family history of cardiovascular disease increased the odds of CAC. The c statistics ranged from to 0.770, with the highest discrimination based on the year 0 revised PDAY risk score that included family history and increased the points for the sex differential. Conclusion The PDAY risk score predicts CAC up to 15 years before its assessment, and risk score change during 15 years affects the risk of CAC

109 Hypertension Jul;56(1): Epub 2010 Jun 1. Joint associations of physical activity and aerobic fitness on the development of incident hypertension: coronary artery risk development in young adults. Carnethon MR, Evans NS, Church TS, Lewis CE, Schreiner PJ, Jacobs DR Jr, Sternfeld B, Sidney S. Source Department of Preventive Medicine, Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Ill 60611, USA. Abstract Fitness and physical activity are each inversely associated with the development of hypertension. We tested whether fitness and physical activity were independently associated with the 20-year incidence of hypertension in 4618 men and women. Hypertension was determined in participants who had systolic blood pressure >or=140 mm Hg or diastolic blood pressure >or=90 mm Hg or who reported antihypertensive medication use. Fitness was estimated based on the duration of a symptom-limited graded exercise treadmill test, and physical activity was self-reported. The incidence rate of hypertension was 13.8 per 1000 person-years (n=1022). Both baseline fitness (hazard ratio: 0.63 [95% CI: 0.56 to 0.70 per SD]; 2.9 minutes) and physical activity (hazard ratio: 0.86 [95% CI: 0.79 to 0.84 per SD]; 297 exercise units) were inversely associated with incident hypertension when included jointly in a model that also adjusted for age, sex, race, baseline smoking status, systolic blood pressure, alcohol intake, highdensity lipoprotein cholesterol, dietary fiber, dietary sodium, fasting glucose, and body mass index. The magnitude of association between physical activity and hypertension was strongest among participants in the high fitness (hazard ratio: 0.80 [95% CI: 0.68 to 0.94]) category, whereas the magnitude of association between fitness and hypertension was similar across tertiles of physical activity. The estimated proportion of hypertension cases that could be prevented if participants moved to a higher fitness category (ie, preventive fraction) was 34% and varied by race and sex group. Fitness and physical activity are each associated with incident hypertension, and low fitness may account for a substantial proportion of hypertension incidence.

110 Risk Estimation in 2009 CIRCULATION Lewis H. Kuller, MD, DrPH CHD is a preventable disease. Individuals who have optimal risk factors have a 5% lifetime risk of a heart attack among men and 8% among women. Could CHD be prevented or reduced to this low lifetime incidence if risk factors could be reduced or actually prevented and low lifetime risk and optimal risk factors increase dramatically above 8% of men and 14% of women? There are 2 options. First, the pharmacological approach to reduction of LDL cholesterol and BP using relatively low-dose therapy applied to most of the population, for example, the polypill, possibly in combination with measures of atherosclerosis to identify more aggressive drug therapies for participants with progressive atherosclerosis even given the polypill therapy.15 Second, substantially change the American diet to a more plant-based diet with higher intake of polyunsaturated omega-3 and omega-6 fatty acids, and reduce sodium and calories to reduce prevalence of obesity.16,17 Increased physical activity and improved cardiovascular fitness may both blunt the obesity epidemic and decrease cardiovascular disease risk.

111 C-reactive protein (CRP) is a protein in the blood that demonstrates the presence of inflammation, which is the body's response to injury or infection; CRP levels rise if inflammation is present. The inflammation process appears to contribute to the growth of arterial plaque, and in fact, inflammation characterizes all phases of atherothrombosis and is actively involved in plaque formation and rupture. According to some research results, high blood levels of CRP may be associated with an increased risk of developing coronary artery disease (CAD) and having a heart attack. [22] In the Jupiter trial, in healthy persons without hyperlipidemia but with elevated high-sensitivity CRP levels, the statin drug rosuvastatin significantly reduced the incidence of major cardiovascular events. [23] The 2010 ACCF/AHA guideline for assessment of cardiovascular risk in asymptomatic adults states that measurement of C-reactive protein can be useful in selecting patients for statin therapy and may be reasonable for cardiovascular risk assessment, depending on the patient s age and risk level. C-reactive protein measurement is not recommended for cardiovascular risk assessment in asymptomatic high-risk adults, low-risk men 50 years or younger, or low-risk women 60 years or younger. [3]

112 Homocysteine is a natural by-product of the dietary breakdown of protein methionine. In the general population, mild to moderate elevations are due to insufficient dietary intake of folic acid. Homocysteine levels may identify people at increased risk of heart disease, but again, due to the lack of agents that effectively alter the homocysteine levels, studies have not shown any benefit from lowering the homocysteine level.

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117 Am J Epidemiol Nov;126(5): Coronary heart disease risk factors in a random sample of Athenian adults. The Athens Study. Moulopoulos SD, Adamopoulos PN, Diamantopoulos EI, Nanas SN, Anthopoulos LN, Iliadi- Alexandrou M. Source Dept. of Clinical Therapeutics, U. of Athens, Greece. Abstract Risk factors for cardiovascular diseases not previously investigated in Greece were studied in a random sample of 4,097 Athenian adults. Mean systolic and diastolic blood pressures increased with age in both sexes. Similar findings were observed for mean serum total cholesterol up to age 50 years, but no significant changes were observed in older persons. Smoking was more common for men than for women and less common in those aged more than 50 years. Mean values of body mass index were higher for men than for women in those less than 45 years, but the opposite was observed for the older age groups. The age-adjusted prevalence rate of borderline hypertension was 10.1% for men and 9.1% for women and of stable hypertension (greater than 160/95 mmhg), 8.1% and 8.6%, respectively; the age-adjusted prevalence rate of obesity was 23.5% for men and 23.2% for women and of hypercholesterolemia (total cholesterol greater than or equal to 260 mg/100 ml), 20.1% for men and 17.3% for women. The associations of age and systolic blood pressure and of age and diastolic blood pressure persisted even after controlling for body mass index, total cholesterol, and smoking. In the examined representative sample, the prevalence rates of risk factors for cardiovascular diseases are the same or greater than those in industrialized countries

118 . Foody J M et al. Arterioscler Thromb Vasc Biol 2000;20: Copyright American Heart Association

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120 . Foody J M et al. Arterioscler Thromb Vasc Biol 2000;20: Copyright American Heart Association

121 In women, the value of Lp(a) for predicting CAD has also been inconsistent. In a recent population-based study of both premenopausal and postmenopausal women, a significant increase in CAD risk (OR=2.9) was observed in those with Lp(a) levels >30 mg/dl versus those in the lowest quartile of their population (<6 mg/dl) This was consistent with the 14-year follow-up of nearly 5000 women in a recent Mayo Clinic study (hazard ratio=1.9), as well as a past study in young women from Framingham. 38 In contrast, analyses of 2 prospective studies, the Stanford Five City Project 39 and a Japanese trial of 337 women with population ages comparable to our own cohort, 24 identified no significant association. Although we found a marginal association between Lp(a) and CAD in women overall, a significant and profound association was observed only when the elevation in Lp(a) was accompanied by a concurrent elevation of serum thcy levels.

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123 Int J Adolesc Med Health Jul-Sep;20(3): Prevalence of smoking among Greek students: a short report. Nikolakopoulou NM. Source The School of Health and Welfare Professions, Patras Highest Institute of Education and Technology, Patras, Greece. nikoletanikolakopoulou@yahoo.com Abstract The aim of this study was to determine the prevalence of smoking and its associated factors among Greek students. Out of 1200 participants, 47% reported smoking, even one or two puffs (50.8% females and 43.8% males). The mean age of initiation of smoking was /- 1.9 years. Living in a single-parent family was not a significant risk factor for smoking. However, having more than one family member who smokes influences the smoking behavior in young people

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