Transcript Title

For Healthy Life
“ Re-planning our Strategies Towards Most Effective
Cardiovascular Prevention”
Athanasios J. Manolis
Director of Cardiology Dep. Asklepeion Hospital, Athens, Greece
Chairman Working Group “Hypertension and Heart” of the ESC
Council Member of the European Society of Hypertension
What is CVD prevention?
“A coordinated set of actions, at public and individual level,
aimed at eradicating, eliminated or minimizing the impact of
cardiovascular diseases and their related disability.
The bases of prevention are rooted in cardiovascular
epidemiology and evidence-based medicine”.
A Dictionary of Epidemiology. 4th ed New York: Oxford University Press; 2001
Ancient Greek Proverb
To prolambanein protimoteron tou qerapeuein esti
Prevention is Preferable to Curing
( The earlier the better )
Hippocrates (c. 460-377 B.C)
Number of Deaths Worldwide/year
40
36 millions
30
23.6 millions
18 millions
20
10
0
NCD
CVD(2012)
CVD(2030)
The Evolution of Mankind
2.5 million years
50 years
What are the Main Targets for CVD Prevention?
Smoking
No exposure to tabacco in any form
Diet
Health diet, low in saturated fat with a
focus on wholegrain products,
vegetables, fruits and fish.
Physical Activity
2.5 to 5 hours moderately vigorous
physical activity per week or 30-60
minutes most days
Body Weight
BMI 20-25 kg/m2 . Waist circumference <
94 cm (men) or <80 cm (women)
Blood Pressure
BP <140/90 mmHg
Lipids
Very high risk: LDL <1.8 mmol/L (70
mg/dL) or >50% reduction
High risk: LDL <2.5 mmol/L (100 mg/dL)
Moderate risk: LDL <3 mmol/L (115
mg/dL)
Diabetes mellitus
HbAIc: <7% (53mmol/mol), BP<140/80
Today’s Portions
Atherosclerosis:
a Multifactorial Disease
Reported Medication Use In Hospital Patients With
Established CHD, 1995/96, 1999/2000 And 2006/07,
EUROSPIRE Survey Populations
100%
90%
80%
70%
60%
50%
EUROSPIRE I
1995/6
40%
30%
20%
EUROSPIRE II
1999/00
10%
EUROSPIRE III
2006/07
0%
Anti-platelet Beta-blockers ACE-inhibitors Lipid lowering
therapy
& AT2
drugs
antagonists
Statins
Reported Medication At Discharge: Hospital Patients With
Established CHD, 2006/07, EUROASPIRE III Survey
2012: Deaths By Cause, in Europe
all other causes
Coronary heart disease
injuries and poisoning
Stroke
Respiratory disease
Other CVD
Stomach cancer
Other cancer
Lung cancer
Colo-rectal cancer
Hypertension Detection and Follow-up Program
B. Stroke
Organ Damage
Organ Damage
No
20
Cardiovascular events (% in 5 years)
A. Total Mortality
Yes
No
Yes
18.7
15.3
10
7.4
5.8
5.4
4.8
2.1
1.3
0
S
U
S
U
S
U
S
U
Zanchetti J Hypertens 2009
The Cardiovascular Continuum :
Treatment Benefits and Residual Risk at Increasing CV Risk
30%
40%
20%
20
10%
22.5
30
37.5
15
10
7.5
50%
50
Treatment Benefits -25%
CV
risk
5%
CV risk
% in 10 years
Death
Zanchetti A. Nat Rev Cardiol 2010;7:66-7
Trials in High-Risk Patients
50.0
50
Major cardiovascular events
(% in 5 years)
43.5
40
40.0
34.
3
30
26.9
27.0
25.6
25.4
25.4
20
17.8
16.8
19.2
15.8
13.0
10
10.5
11.7
11.2
12.4
11.0
11.5
8.5
12.1
12.0
10.5
10.6
11.0
ACC CAM PEA
EU
INV
JM
ALL
68
60
23
13
13
68
65
0
132
60
65
3
100
57
92
102
128
66
28
32
5
100
22
37
57
0
131
65
22
42
100
28
55
0
136
67
36
8.0
14.1
14.0
12.5
Residual
Risk
16.1
13.9
13.9
LIFE ACT ONT
TR
HOP VAL PROG TIA PROF PATS MOS
67
36
16*
8
25
100
0
144
67
36
46
22
91
13
55
79
131
136
66
38
52
11
88
8.5
28
76
101
135
11.4
14.0
12.2
11.7
8.3
0
Trial
Age (y)
DM (%)
MI (%)
Stroke (%)
Any CVD (%)
LVH (%)
LLT (%)
APT (%)
AHT (%)
SBP (mmHg)
57
18
38
4
100
86
94
139
124
64
17
55
7
100
70
90
109
129
} 23
52
16.5
25
36
0
135
64
15
52
100
68
86
37
130
64
37
49
21
91
13.6
62
81
118
133
67
32
46
20
60
15
46
73
0
139
64
13
16
100
100
7
60
50
132
65
5
6
100
100
11
49
0
150
66
28
100
100
15.5
47
100
103
136
60
100
100
0
143
68
37
8
100
100
31
78
0
136
Zanchetti J Hypertens 2009
Adults With Diagnosed Diabetes*
7.3% DM Prevalence
4.9% DM Prevalence
2000
1990
11.1 % Obesity
No data
available
Less than 4%
19.8 % Obesity
4%-6%
Above 6%
*Includes women with a history of gestational diabetes.
Mokdad AH, et al. JAMA. 2001;286(10):1195-1200.
Achieved BP in Trials
Previous CVD
Diabetes
SBP (mmHg)
SBP (mmHg)
160
170
155
150
PL
154
140
130
145
Active
145
144
143
144
143
140
139
134
134
138
140
145
143
150
149
143
140
153
148
CHD
150
150 PL
162
160
Stroke
141
140
Active
136
144
130
141
137
132
133
133
135
136
136
133
130
130
130
130
128
136
132
140
138
124
120
132
129
124
122
128
120
119
110
100
110
HOT
UKPDS
S. Eur
ADV
SHEP
HOPE
PROG
ABCD IDNT
HT
NT
IDNT
NAV
REN
ACRD
IR
AM
preDM
BP
 Benefit
PATS
ACC
PROG
PROF
HOPE CAM-AM
EU
TR
PREV
CAM-EN
ACT
PEA
No benefit
Zanchetti, Grassi, Mancia J Hypert 2009; 27: 923
Change In Smoking Rates Among 15 Year Olds,
By Sex, 1993/94 To 2009/10, Europe
Health Behaviors and Attitudes in Young and Middle-Aged
Saint-Petersburg Citizens (Russia) : A Pilot Study
Parameters
Tobacco smokers
Young participants
(<4 years old)
(n=75)
Older participants
(≥40 years old)
(n=28)
P-value
26(34.7%)
5(17.9%)
NS
Alcohol Consumption
Each day
1(1.3%)
Alcohol Consumption
One or several times
per week
23 (30.7%)
4 (14.3%)
<0.05
Regularly (at least once
per week) participate in
active leisure or sport
40( 53.3%)
12 (42.9%)
NS
Systolic BP (mmHG) (M
 m)
123.9  1.9
147.2  4.6
<0.001
Systolic BP>140mmHg
11 (14.7%)
15 (53.6%)
<0.001
Diastolic BP>90mmHg
7( 9.3%)
5 (17.9%)
NS
14 (18.7%)
7 (25.0%)
NS
BMI >25 kg/m2
Praying or Acting?
Dear God
My prayer for 2012 is for
A fat bank account and a thin body
Please don’t mix these like you did last year
AMEN !
2007 ESH/ESC Guidelines
Lifestyle Changes in MS
Modest  of caloric intake
 Saturated fat < 7%
 Transfatty acids
 Cholesterol <200 mg
 Simple carbohydrates 50%
 Fruit / vegetables
 Whole grain
 Physical exercise
30 min daily of
moderate exercise
At least 7-10%  BW in 6-12 months
Marked reduction (~60%) of NOD
Marked reduction (~40-50%) of MS prevalence
Exercise Capacity and Mortality in Black and White Men,
in Diabetics, Prehypertensives, and High Risk
RR of all cause mortality in individuals with no CVD
Relative Risk
1.2
1
0.79
0.79
0.8
0.6
0.51
0.52
0.27
0.4
0.2
0.78
0.5
0.23
0.3
0
ALL
AfricanAmerican
Caucasian
Kokkinos P, Pittaras A, Manolis AJ et al. Circulation 2008
Kokkinos P, Pittaras A, Manolis AJ et al. Am J Hypertens. 2009
Kokkinos P, Pittaras A, Manolis AJ et al. Diabetes Care 2009
Kokkinos P, Pittaras A, Manolis AJ et al. Hypertension2009
Score® – 10-year risk of fatal CVD
POWER Study: Evolution of Score®
Mean SCORE® risk at V3 3.5  3.5%
8%
≥15%
Mean Score® change = -2.5 3.1%
1%
12%
10-14%
Relative Risk reduction of - 41%
3%
28%
5-9%
24%
17%
19%
3-4%
p<0.001
13%
16%
2%
22%
≤1%
37%
0
5
10
15
20
25
30
35
40
Baseline visit
Final visit
Percentage of patients
The Polypill
 Three antihypertensive drugs
Beta-blocker
ACE-inhibitor
Diuretic
 Statin
 Low dose aspirin
Potential Cumulative Impact of
Four Single Secondary Prevention Treatments
Relative risk
reduction
2-year
event rate
None
---
8%
Aspirin
25%
6%
Beta-blockers
25%
4.5%
Lipid lowering (by 1.5 mmol)
30%
3.0%
ACE inhibitors
25%
2.3%
Cumulative relative risk reduction if all four drugs are used is
about 75%
Polypill and Cardiovascular Cost
CV Disease Cost
$ 863 billion globally
Polypill
17.9 million deaths in 10 yrs
Driving Behavioral Change and Improving
Health and Productivity
October 2012
27
What is KNOW YOUR NUMBERS?
Know Your Numbers is a cardiovascular risk
assessment tool designed to help drive health
improvement and behavioral change.
 KYN and a healthy lifestyle can:
 Prevent onset of metabolic conditions
 Help reverse chronic metabolic
conditions and prevent individuals
living with these conditions from getting
worse.
 Increase morale
How Know Your Numbers Works
Assessment Output
Biometric Input



KYN
Lab Values

Fasting Glucose

Lipid Panel
Clinical Measures

Height

Weight

Waist

Blood Pressure

Pulse Rate
Synthesis
Analysis
Engine
Chronic Disease
Risk for:
Limited Health History
Provides Powerful, Actionable
Knowledge
Heart Disease
Stroke
Diabetes
Heart Failure
COPD
Lung Cancer
Other Cancer
Why Know Your Numbers in Russia
 KYN has consistent results in helping patients identify their
cardiovascular risk factor, the main cause of death in Russia
today.
 KYN allows patients to be pro-active and engaged with their
healthy lifestyle by providing more opportunities to be educated on
proper nutrition and physical fitness.
 92% of participants of KYN in other countries have been able to
reduce or eliminate cardio-metabolic risk factors, which is much
needed in Russia, a country where cardiovascular risk is growing
compared to other parts of Europe where these risks have shown a
decline.
 KYN coincides with President Putin’s goal in dedicating more
funding to these types of programs.
 The 2012 national budget has 820 million Rubles allocated for healthy
lifestyle.
 Cost of healthcare is growing worldwide and KYN’s model shows a
reduction in costs associated with cardiovascular diseases.
 NOW IS THE RIGHT TIME FOR RUSSIA!
Worldwide locations where Know Your Numbers has
been implemented (2005-2012)
30
Organization Participating in Know Your Numbers
Around the World
Program Sponsor*
Locations
Market Segment
Abbott (2006, 2008, 2009)
Illinois, UK, Puerto Rico, Chile
Private Payer
TriCity Challenge (2005 - 2006)
Navistar
Chevron
ArvinMeritor
Wayne County Airport Authority
Illinois, Ohio (3 locations)
Houston, TX
Detroit, MI
Detroit, MI
Toyal America (2009, 2010, 2011)
Illinois
Dreyer Medical Clinic (2008)
Illinois (3 locations)
Health Care System
St. Luke’s Hospital System (2007)
Kansas
Health Care System
Family Doctors
MA
MC-21 (2009-2010)
Puerto Rico
State of Washington (2008)
Washington (5 locations)
Public Payer
Military (2008)
Singapore
Public Payer
City of Albuquerque (2008)
New Mexico
Public Payer
Santa Cruz County (2010-2011)
CA
Public Payer
SuperValu (2010)
Illinois
Private Payer
Private Payer
Health Care - Group Practice
Health Care - PBM
Retail
*Initial enrollment of participants are not reflected in this data, only those that attended both pre and post health screenings
required to capture data to measure health improvement results . Data includes 2,611 participants.
Know Your Numbers &
Behavioral Change Program Components
 Pre and Post Challenge screenings
 Individual chronic disease risk assessment (KYN report)
 Educational sessions on key health topics (nutrition, physical
fitness)
 Team or individual competition
 Reward and recognition program
 Summary data of health improvements
Risk of Onset, Modifiable Risk and
Risk Comparison for a 45 male participant
He has an 36% chance of developing type 2
diabetes in the next 5 years
Compared to other 45
yr old men, 98% have
a lower risk of
diabetes than he does
Being in the 98%
percentile (compared to
his peers) puts his
diabetes risk in the
Relatively High category
92% of his diabetes
risk is in his control
(modifiable)
Risk Factors with the Most Impact on Disease Risk
Reduction
Smoking is a major risk factor that is contributing a majority of
his disease risk. By modifying just this one risk factor, he
would decrease his risk of onset for several conditions
significantly.
Provides the participant with an Action Plan!
Automated Treatment/Action Plan Report
Physicians receive a treatment
action plan report based on
widely accepted guidelines for
the region which helps save time
and encourages consistent
therapy.
Abbott Puerto Rico-Success Story
(August-November 2009)
 624 employees began the Challenge
 233 employees completed the Challenge
 Average reduction per person
 weight loss of 9.5 lbs
 waist reduction of 2.9 inches
0
20
23%
CHD
40
45%
New onset
55% Type Diabetes
60
Mets
80
93%
100
weight
91%
Waist size
28%
Stroke
How are some partners using Know Your
Numbers in helping to promote a healthy
lifestyle in Russia?
Pilot in Kazan
Epidemiology of CV Disease in HIV Patients
 Patients living longer with HIV are presenting new
concerns related to ART and chronic viral infection
 The risk for CVD may be greatly elevated in the HIV +
population for a number a reason:
-Increased prevalence of known CAD risk factors
(smoking, HTV, etc)
-HIV virus-related pathology?
-ART-related lipodystrophies, dyslipidemias,
diabetes mellitus, insulin-resistance, etc.
Health Promotion February 10, 2011
Company Confidential
Social Partner Development Fund
(People Living With HIV)
 Non-profit organization established in 2005 to develop
public health care facilities in combating diseases of
social significance.
 The mission of the Fund is to improve people’s quality
of life through constructive interaction between all
parties involved in the public health system.
 The strategy of the Fund is based on the fact that a
key factor in ensuring the sustainable development of
public health care in the fight against socially
significant diseases in the current climate is the
involvement in these processes of—and the level of
interaction between—the government, the private
sector and civil society.
Social Partnership Development Fund: Pilot Overview
Participants – 250 HIV+ patients to be enrolled
Locations: Kazan (a diverse population of over 1.1 million people)
Patient enrollment began on September 1, 2012 and baseline
measurements were taken to evaluate cardiovascular risk, utilizing
the unique tool, Know Your Numbers, that provides a predictive look
at future risk of developing chronic diseases.
12-week follow up with patient support and education by doctors
and experts on nutrition, physical fitness, and benefits of less
alcohol and tobacco use.
Re-evaluation of the participants risk after the intervention to
identify progress.
Results of the pilot to be available in Qtr1, 2013.
Russian Preliminary Baseline Data
(As of 10/5/12)
 29 participants enrolled to date (expect 250)
 20 female / 9 males
 32 mean age
overweight or
total cholesterol
triglycerides
hypertensive
LDL
cholesterol
obese
pre-hypertensive
pre-diabetes
0
2%
10
10%
20
21%
24%
30
31%
40
50
55%
60
31%
Where should CVD prevention programmes be offered?
Actions to prevent CVD should be incorporated into everyone’s daily lives, starting in early childhood and
continuing throughout adulthood and senescence
The physician in general practice is the key person to initiate, coordinate and provide long-term follow-up
for CVD prevention.
Nurse-coordinated prevention programmes should be well integrated into healthcare systems
The practising cardiologist should be the advisor in cases where there is uncertainty over the use of
preventive medication or when usual preventive options are difficult to apply
All patients with CVD must be discharged from hospital with clear guideline-orientated treatment
recommendations to minimize adverse events
All patients requiring hospitalization or invasive intervention after an acute ischaemic event should
participate in a cardiac rehabilitation programme to improve prognosis by modifying lifestyle habits and
increasing treatment adherence.
Patients with cardiac disease may prticipate in self-help programmes to increase or maintain awareness
of the need for risk factor management.
Non-governmental organisations are important partners to health care workers in promoting preventive
cardiology
The Eyropean Heart Health Charter marks the start of a new era of political engagement in preventive
cardiology.
To Smoke or not to Smoke
RussiAction
TARGETS 2012-2015
Modifiable Risk Factors
Physical activity Tobacco
10%
30%
Salt intake
Blood Pressure
control
30%
25%
25% in mortality
Global CV Disease Task Force 2012
TARGETS 2012-2015
Plus :
 Fat intake
 Cholesterol
 Obesity
 Excessive alcohol intake
 Drug therapy
RussiAction
Government
Politicians
Army
Opinion leaders
Actors
Olympic champions
Media
Cardiovascular Societies
Doctors
Nurses
Volunteers
Foundations
Companies
Doing Nothing in CV Prevention
$500 billion/year
in low and middle income
countries
$47 trillion cost in the next 25 yrs
Conclusions
We now have the opportunity to make important
changes in our countries by adopting evidence-based
targets and implementation of the guidelines that will
guide health policy, with the collaboration of the
government, national societies, parents, teachers,
nurses, volunteers, politicians and opinion leaders.
Collaboration with other groups, such as stakeholders,
foundations, media etc. will be necessary to address
this emerging 21st global health priority and begin to
reverse the devastating toll of CV disease and NCDs
in our communities.
Zakynthos Island, Greece
Santorini Greece