Early detection and Management of CVD/NCD Dr Shanthi Mendis MBBS MD FRCP FACC Coordinator, Chronic Disease Prevention & Management World Health Organization Geneva Switzerland

What is the reality screening/management? What is the primary health care approach ? Why an integrated approach? To what extent can EB interventions be integrated into primary care?

Noncommunicable diseases/CVD CVDs lead and are getting worse CVDs /NCDs are undetected Public funding for health inadequate Excellent experts and good hospitals Not enough is done in primary care Not enough is done in prevention Need to strengthen primary care/ PHC approach

2. NCD prevention and control and primary health care approach ?

Screening Screening of RF Screening for disease Clustering of RF Incubation period

Cardiovascular disease Atherosclerosis Cardiovascular disease Myocardial infarction Globalization, Ageing, urbanization Tobacco, alcohl, unhealthy diet (salt and fat), physical inactivity, Obesity, diabetes, hypertension, hypercholesterolemia, Albuminuria, poverty Stroke

Cost effectiveness and affordability Primary prevention population-wide Tobacco, salt, trans fat, fruits/veg Very cost effective Cost effective Cost effective if targeted at high risk people Secondary prevention Primary prevention at individual level

Cost of implementation There affordable interventions to prevent NCDs Disease/risk factor Intervention Cost of implementation Health impact Cost-effectiveness Risk factors Tobacco use Excise tax on tobacco products Low Large Very cost-effective Smoke-free workplaces Modest Quite cost-effective Packaging, labelling and awareness countermeasures Comprehensive ad bans Harmful use of alcohol Excise tax on alcoholic beverages Unhealthy diet and physical inactivity Reduce salt intake Food taxes (fat) and subsidies (fruit and vegetables) Intensive counselling Very high Non-communicable Diseases Diabetes Glycaemia control High Cardiovascular diseases Hypertension drug treatment Cancer Treatment of 1st stage breast cancer Cervical cancer screening (PAP smear) and treatment Respiratory disorders Inhaled corticoid-steroids for asthma Small

Management Primodial prevention Primary prevention Secondary prevention CABG, PTCA/Stents Integrated NCD policy

Requirements for NCD/CVD Prevention and Control Health impact of policies outside health PHC Approach environments Conducive Social determinants Intersectoral action

Primary Health Care Governance Health workforce (teams?) Infrastructure Health financing Medicines and technologies Health information systems Referral links People centered care with continuity Dialogue between levels and sectors Equitable resource allocation

3. Why an integrated approach in PHC?

Noncommunicable diseases Prioritize and Integrate Diabetes Cardiovascular disease Chronic respiratory disease Cancer Others ……..prevention of renal disease

Noncommunicable diseases Why do we need an integrated approach ? Risk factors are shared Much common between heart disease and stroke Risk factors cluster together (central obesity, IGT, hypertension, dyslipidemia) 60% of diabetics die of heart attacks and stroke Tobacco cessation is essential for improving outcomes of diabetes and CVD There are many diabetics that suffer from Chronic respiratory disease Diabetes / hypertension commonest causes of renal failure Too many guidelines and too little implementation

Why an integrated approach in PHC? It is not enough to manage NCD/CVD only in large hospitals Lot can and need to be done in primary care Prevention needs to be strengthened by action outside health sector

Noncommunicable diseases Cardiovascular disease Chronic respiratory disease Diabetes Prevention of renal disease Cancer epilepsy etc

WHIO Package of Essential NCD Interventions Assess capacity Estimate costs Requirements (skills, equipment, medicines) Simple Integrated protocols evidence based interventions Strict referral criteria Integrated training materials Tools for self management /adherence Health information system- clinical record computerised Monitoring and evaluation

Scope Tobacco cessation Promotion of healthy diet/ physical activity Diabetes Cardiovascular risk (Hypertension / hypercholesterolemia ) Prevention of kidney disease Cerebrovascular disease Coronary heart disease Asthma Chronic obst. Pulmonary Dis. Early detection of cancer Cancer pain care Rheumatic heart disease

WHO/ISH charts Screen for risk of heart attacks and strokes G E   MALE FEMALE SBP Non-Smoker Smoker 180 160 70 140 120 60 50 40 4 5 6 7 8 Cholesterol WHO/ISH charts Screen for risk of heart attacks and strokes Using simple variables Age Smoking Sex Blood pressure Blood cholesterol Blood sugar Intervene based on risk and affordability

WHO Package for integration of Essential NCD interventions Provides technical support to Assess capacity and situation Identify gaps / needs Train health care workforce Integrate where there is added value Improve clinical practice patterns Assess cost of integration of NCDs Tools to monitor and evaluate Improve compliance

Role of PHC Detect (asymptomatic) high risk early Diagnose. treat and follow-up Prevent premature death Reduce costs of complications (amputations, renal dialysis, bypass surgery, blindness) Reduce admissions to hospitals (catastrophic health expenditure)

Apply protocol to all the following: Protocol: 1P Prevention of heart attacks, strokes and kidney disease, integrated management of diabetes and hypertension (assessment and management of cardiovascular risk using hypertension, diabetes and tobacco use as entry points) Apply protocol to all the following: Age > 40 years Smokers Waist circumference >=90 cm in women and 100 cm in men Raised BP Diabetes Family history of premature CVD Family history of diabetes or kidney disease FIRST VISIT Action 1. Ask about: Known heart disease, stroke, TIA, diabetes, kidney disease Angina, breathlessness, claudication Medicines that the patient is taking Current tobacco use (yes/no) Alcohol consumption (yes/no) Occupation (sedentary or active) Engaged in more than 30 minutes of physical activity at least 5 days a week (yes/no)

Protocol: 1P (continued) Action 3: Referral criteria for all visits: BP ≥140 or ≥ 90 mmHg in people < 40 years (to exclude secondary hypertension) Known heart disease, stroke, TIA, DM, kidney disease (for assessment as necessary) Angina, claudication Worsening heart failure Raised BP ≥140/90 ( in DM above 130/80 mmHg) in spite of treatment with 2 or 3 agents If albuminuria >= 2+ Newly diagnosed diabetes in lean persons of <30 years DM with blood glucose >14 mmol/l despite maximal metformin with or without sulphonylurea DM with severe infection and/or foot ulcers DM with recent deterioration of vision or no eye exam in 2 years FIRST VISIT Action 2. Assess: Waist circumference Palpation of heart, peripheral pulses and abdomen Auscultation heart and lungs Blood pressure Fasting or random blood glucose (DM= fasting>= 7 mmol/L or random>=11.1 mmol/Ll) Urine albumin Test sensation of feet if DM Action 4. Estimate cardiovascular risk in those not referred : Use the WHO/ISH risk charts relevant to the WHO subregion (Annex and CD) Use age, gender, smoking status, systolic blood pressure, diabetes (and blood cholesterol if available) If age 50-59 years select age group box 50, if 60-69 years select age group box 60, etc.; for people age < 40 years select age group box 40

Protocol: 1P (continued) Action 5. Treat as shown below FIRST VISIT All individuals with persistent raised BP ≥ 160/100 mmHg should be given antihypertensive treatment All individuals with persistent fasting blood glucose > 6 mmol/l despite diet control should be given metformin All patients with established diabetes and cardiovascular disease (coronary heart disease, myocardial infarction, transient ischaemic attacks, cerebrovascular disease or peripheral vascular disease); if stable, should continue the treatment already prescribed and be considered as with risk >30% Risk < 20%: Counsel on diet, physical activity, smoking cessation (Protocols 3 and 4) Follow up every 3 months until targets are met, then 6 - 9 months thereafter Risk 20 to <30%: Counsel on diet, physical activity, smoking cessation (Protocols 3 and 4) Persistent BP ≥ 140/90 mmHg (in DM ≥ 130 /80 mmHg) consider a low dose of one of the drugs: hydrochlorthiazide 25-50 mg daily, enalapril 5-20 mg daily, atenolol 50-100 mg daily, amlodipine 5-10 mg daily Titrate oral agents until blood glucose level at target Give simvastatin 10-40 mg daily if DM Follow up every 3-6 months Risk > 30%: Counsel on diet, physical activity, smoking cessation Persistent BP ≥ 130/80 should be given of one of the drugs: thiazide, ACE inhibitor, beta-blocker, calcium channel blocker Give simvastatin 10-40 mg daily Give aspirin 75-150 mg daily Follow up every 3-6 months

Protocol: 1P (continued) SECOND VISIT Repeat Actions 2, 3 and 4 Follow referral criteria for all visits (see Action 3) Treat as shown below If risk is < 20%, follow up in 12 months and reassess cardiovascular risk Counsel on diet, physical activity, smoking cessation (Protocols 3 and 4) If risk is 20 to <30%, continue as in Action 4 and follow up in every 3 months If risk is still > 30% after 3-6 months of prescribed interventions at first visit, refer to next level Advice to patients and family •If you are on any diabetes medication that may cause your blood glucose level to go too low, carry sugar or sweets with you •Have your blood glucose level, blood pressure and urine checked regularly •If feasible, have your eyes checked every year •Avoid walking barefoot or without socks •Wash feet in lukewarm water and dry well especially between the toes •Do not cut calluses or corns, nor use chemical agents on them •Look at your feet every day and if you see a problem or an injury go to your health worker Avoid table salt and reduce salty foods such as pickles, salty fish, fast food, processed food, canned food and stock cubes

Thank You