Global burden of Cardiovascular Diseases Andrew M Tonkin, MD PROJECTED GLOBAL BURDEN OF CVD CVD Deaths (millions) 25155 Established market economies and former socialist economies of Europe Demographically developing countries 1990 Global CVD Deaths B.
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Global burden of Cardiovascular Diseases Andrew M Tonkin, MD PROJECTED GLOBAL BURDEN OF CVD CVD Deaths (millions) 30 25 6 20 15 10 5 5 19 Established market economies and former socialist economies of Europe Demographically developing countries 9 0 1990 Global CVD 2020 Deaths B. Neal et al. Eur. Heart J 2002 GLOBAL BURDEN OF DISEASE: COMMON CVD RISK FACTORS Risk factor Exposure Variable High BP Usual SBP Tobacco Smoking impact ratio; oral tobacco use High cholesterol Usual TC High BMI BMI Low fruit and veg. Intake Inactivity Global CVD Theoretical Minimum Contribution to GBD 115mmHg (SD6) 4.4% No use 4.1% 3.8mmol/L (SD0.6) 2.8% 21kg/m2 (SD1) 2.3% Intake daily 600g (SD50) 1.8% Categories >2.5h/week, mod. 1.3% M. Ezzati et al. Lancet 2003;362:271-80 EPIDEMIOLOGIC TRANSTION Age Pestilence and famine Receding pandemics Degenerative “man-made” diseases Delayed degenerative diseases Predominant CVD Rheumatic heart disease Hypertensionrelated diseases CHD, stroke, diabetes at young ages CHD, stroke at older ages % of deaths due to CVD 5-10 10-35 35-65 <50 Current examples Sub-Saharan Africa Rural China Urban India North America, Australasia Global CVD From S Yusuf et al. Circulation 2001;104:2746-53 DRIVERS OF THE CVD EPIDEMIC • Urbanisation • Global trade and marketing developments • Tobacco industry • Physical inactivity Tobacco use, inappropriate diet and physical inactivity (expressed through unfavourable lipid profiles, overweight and raised BP) explain at least 75% of new CHD cases Global CVD CHD TRENDS IN BEIJING 1984 TO 1999 Global CVD Critchley J et al. Circulation 2004;110:1236-1244 CURRENT AND PROJECTED POPULATION PERCENTAGES FOR 2000, 2020 AND 2040 % population 65+ 30 25 20 15 10 5 0 S. Africa India Brazil 2000 China 2020 Russia Portugal 2040 U.S. S. Leeder 2003 CVD IN AUSTRALIA: 11% TOTAL HEALTH SPENDING Total $6,563.7m Inpatients Outpatients 5% 5% 10% 41% 6% 3% Research 26% OHPs 1% Pharmaceuticals 4% 4% Aged care GPs Imaging & pathology Out-of-hospital specialists USE OF MEDICATION IN STROKE AND CHD Aspirin 96 95 % 100 90 83 89 81 79 80 70 Statins 78 66 78 66 58 60 50 38 40 29 30 20 31 28 23 16 9 10 38 28 0 Brazil Global CVD Egypt India Indonesia Iran, Pakistan Sri Lanka Islamic Republic of Turkey Russian Tunisia Federation WHO PREMISE project, 2002 ANTIHYPERTENSIVE DRUGS Available Affordable Locally manufactured 57% 48% 7% 45% 74% 64% 88% 92% 46% 70% Africa Americas 67% 91% 30% 89% 83% 100% Eastern Europe Mediterranean 96% 71% South-East Asia Western Pacific Percentage of countries in each region where drugs are available, affordable to low income groups, or manufactured locally Global CVD WHO 2001 POLYPILL: EFFECTS AFTER TWO YEARS, AGE 55-64 RRR (95% CI) (%) Factor Agent Reduction IHD Stroke LDL-C Statin 1.8 mmol/L 61 (51,71) 17 (9-25) Three agents, half dose 11 mmHg DBP 46 (39-68) 63 (55-70) Platelet funct. ASA (75mg) Not quant. 32 (23-40) 16 (7-25) Homocysteine Folic acid, (0.5mg) 3 μmol/L 16 (11-20) 24 (15-33) 88 (84-91) 80 (71-87) BP Combined Polypill All BMJ, 28 June 2003 FIVE-YEAR HARD CHD EVENTS HHP Japanese American Men Deciles based on Framingham function Absolute risk D'Agostino, Sr, R. B. et al. JAMA 2001;286:180-187 FRAMEWORK CONVENTION ON TOBACCO CONTROL Key provisions encourage countries to: • Enact comprehensive bans on tobacco advertising, promotion and sponsorship; • Obligate placement of rotating health warnings on tobacco packaging that cover at least 30% (but ideally ≥ 50%) of principal display areas; • Ban use of deceptive terms such as “light” and “mild”; • Protect citizens from exposure to tobacco smoke in workplaces, public transport and indoor public places; • Combat smuggling, including placing of final destination markings on packs; • Increase tobacco taxes Tobacco PUBLIC HEALTH POLICY • Comprehensive health programs led by primary care • Appropriate balance between primary and secondary prevention • Particularly population approaches (Only 5% in wealthy countries at ideal cholesterol, BP, weight) • Also high-risk approaches to primary prevention (although latter may increase inequalities) • Acute management and secondary prevention • Surveillance and monitoring Global CVD NCD PREVENTION AND CONTROL 94% 88% 88% South-East Asia Western Pacific 76% 65% 39% Africa Americas Eastern Europe Mediterranean Percentage of countries with integration of components of NCD prevention and control programmes in primary health care Global CVD WHO 2001 PRIORITIES FOR DEVELOPING COUNTRIES • Control strategies, initially based on extrapolation from knowledge from other population, e.g. tobacco control: whole population initiatives • Cross-sectional surveys (ecological comparisons), case-control studies and prospective longitudinal studies for incidence data • Workforce training and capacity building • Low cost, high yield interventions CHD prevention PRIORITIES FOR DEVELOPED COUNTRIES • Prevention including implementation of proven strategies • Chronic disease strategies • Health inequalities • Primary care strategies • Strategies to combat overweight CHD prevention