Principles of

epidemiology and
preventive cardiology

Hana Rosolova
Center of Preventive Cardiology
2nd Department of Internal Diseases
Charles University Prague Medical
Faculty in Pilsen
 Epidemiology

Epidemiology is the science concerned

with the control of epidemic events
i.e. common events, diseases with
high prevalence in the population.
Epidemiology of the infectious (contagious)
diseases since 19th till 1930s of the 20th C.
Epidemiology of the common non-infectious
chronic diseases - problem of the 20th and
21th centuries - atherosclerosis
 Cardiovascular
epidemiology

= basic science for Preventive

Cardiology

CVD epidemiology started after the 2 nd world war

(1945) in USA
Coronary heart disease was the leading cause of
death (50% of all deaths) during 1930-1950 in US.
1960s European West countries

1970s European East countries

Past two decades developing countries over the

world
 Cardiovascular
epidemiology

Nestors: G. Rose a H. Blackburn

Cardiovascular Survey Methods
(1st edition- WHO Geneva 1968)

Ten-Day Teaching Seminars ( ISFC)

 Cardiovascular
epidemiology
general aims

To determine the amount of disease in a

population
To assess distribution of disease within a
population
To study the natural history of disease
Description of the characteristics of healthy
persons
Formulation and testing of etiological
hypothesis
 Epidemiology approach
versus clinical approach

EA population studies CA clinical studies

Population - probands Patients
Group approach Personal approach
Be sceptic to the data Believe the patient
symptoms
Quantity interpretation Quality interpretation
Data have to be presented Medical secret
 Cardiovascular epidemiology

Scientific methodology types of

population study:

Observational studies
Prevalence study - cross-sectional studies
Incidence study - longitudinal studies:
prospective, retrospective
Interventional studies (trials)
 Types of population
study

Cross-sectional studies
present a picture of disease in a population at a
particular point in time.
Single examination relatively cheap and quick !

Number of persons with condition (as defined)

Prevalence rate = ---------------------------------------------------------- x 100
Number of persons examined
 Cross-sectional studies -
limitations

A prevalence estimate in itself reveals

nothing definite about the real
frequency with which a disease arises

e.g. a disease with a high mortality will have a

lower prevalence rate than another form that
has the same incidence but a lower mortality
Incidence and prevalence of diseas

incidence

prevalence

health death
 Cross-sectional studies -
compensations

Prevalence surveys must usually cover

large number of persons in order to find
an adequate number of cases for
meaningful comparisons etc.

Collecting retrospective information

 Types of population
study

Longitudinal prospective studies

start a s cross-sectional survey, but is followed
by reassessment.
 Longitudinal prospective
studies - advantages

Number of new cases occuring in period

Incidence rate = ----------------------------------------------- x
100
Number of persons at risk x length of
period

more comprehensive picture of the true amount of

disease
in the population than cross-sectional study!
 Longitudinal prospective
studies - advantages

description of natural history of the

condition (how often and how fast it
progresses or regresses etc.)

calculation of the risk of developing

disease according to some
characteristics (risk factors)
 Longitudinal prospective
studies - disadvantages

more costly
large study population
need more time
drop out during follow-up
 Longitudinal studies

a) prospective (cause impact) e.g. Is

smoking a risk factor for myocardial infarction?
Intensive method contribute to the causality

b) retrospective (impact cause) e.g. are

the patients with lung carcinoma more often smokers?
Extensive method
 Interventional population
studies
1. precise statement of the hypothesis to be tested
2. recruitment of the study population
3. initial examination of participants
4. random allocation to treatment and control group
5. steps to ensure adherence of treatment regimen
6. checks on adherence to the regimen
7. assessment of progress
8. analysis
 Interventional population
studies (trials)

resolve the causality of the disease

contribute to the disease prevalence
to the diseases etiology
evaluate an effective treatment
contribute to the disease prognosis
give a possibility of disease prevention
 Causality

causality = statistical subject

Causal factor (e.g. Cholesterol level) is in
association with
the disease (AS) and this association has to be:

long-term
strong
specific
time dependen
 Causal
factor

essential but not sufficient (e.g. BK and TB)

sufficient but not essential (e.g. Reduction of energy intake

and weight reduction)

essential and sufficient (e.g. HIV - AIDS)

not essential and not sufficient (e.g. Smoking and lung

cancer)

Causal factor is a factor which modification reduce the

incidence of the disease (G. Rose)
 Risk factor

Characteristic or event, that is in long-term,

strong and repeated association with the
disease

Blood pressure, plasma cholesterol level, glucose

level Quantitative variable (Pickering)

Qualitative variable - smoking, alcohol

consumption, physical activity, salt intake in
the diet etc.
 General source of the
common diseases are in
life style of the
population!

Fatty nuttrition (cholesterol) atherosclerosis

Smoking lung cancer
High salt intake hypertension
Overeating + sedentary life style obesity,
metabolic syndrome type 2 diabetes
mellitus
High alcohol consumption liver cirhosis
Chronic stress depressive syndrome
 Risk factors of
cardiovascular disease
(CVD)
I. Influenceable life style factors: nutrition,
smoking, high alcohol consumption, low physical
activity

II. influenceable biochemical and

physiological factors: total cholesterol, LDL-
chol., low HDL-chol, TG, BP, glucose level, insulin
resistance, fibrinogen, total homocystein etc.

III. Not influenceable factors: age (men over

45y, postmenopauzal women), sex (male), family
history ( any CVD in mother below 65y and father
below 55y), personal history of CVD
Risk factor distribution
in populations
Number (%) Normal BP hypertenson

25 50
risk

20 40
SBP
distribution
15 30 curve

10 20

5 10 Number
of cases

0 0
100 120 140 160 180 200

Systolic blood pressure (SBP-mmHg)

 Cardiovascular
epidemiology

General source of disease environmental factors

classical epidemiology

Genetic background of disease classical genetic

Interaction of environmental and genetic factors

- genetic epidemiology
 The main goals of Preventive
Cardiology

1. To prevent the development of

common chronic non-infectious
diseases CVD (Atherosclerotic
vascular diseases-AVD)

2. To prevent progression, recurrence

of acute events and related
morbidity of
CVD (AVD)
 Strategy of CVD
prevention

Physician model individual approach

to high risk person (primary
prevention) or to a patients with CVD
(secondary prevention)
prevention

Life style intervention

Pharmacological therapy of risk factors
 Strategy of CVD
prevention

Population model approach to the

general population event. to the
high risk population life style
intervention!

The main aim: to shift the distribution curve

of RFs to the left to reduce disease
incidence and prevalence.
 Population model of
CVD prevention
Examples:
Reduction of mean SBP by 8 mmHg and DBP by 4
mmHg in a population - decreases the
prevalence of hypertension about 50% !
Reduction of mean weight by 2.5 kg in a population-
decreases the prevalence of obesity about 50%
Reduction of mean plasma cholesterol level by 1%
decreases the prevalence of acute coronary
syndrome about 20%
 Take home message 1
Epidemiology = basic science for
Preventive Cardiology

Types of population studies:

Cross-sectional - prevalence, retrospective
and prospective observational-
incidence, interventional trials -
causality
 Take home message 2
Causal risk factor is in association with
the disease (AS) and this association has to
be: long-term, strong, specific, time
dependent

Two aims of Preventive Cardiology:

1. To prevent the development of common chronic
non-infectious diseases - CVD

2. To prevent progression, recurrence of acute

events and related morbidity of CVD
 Take home message 3

Strategy of CVD prevention:

1. Physician model primary and

secondary prevention: life style
intervention + pharmacotherapy
2. Population model - life style
intervention