Global burden of Cardiovascular Diseases Andrew M Tonkin, MD

PROJECTED GLOBAL BURDEN OF CVD Global CVD B. Neal et al. Eur. Heart J 2002

GLOBAL BURDEN OF DISEASE: COMMON CVD RISK FACTORS Risk factor Exposure Variable Theoretical Contribution Minimum to GBD High BP Usual SBP 115mmHg (SD6) 4.4% Tobacco Smoking impact ratio; No use 4.1% oral tobacco use High cholesterol Usual TC 3.8mmol/L (SD0.6) 2.8% High BMI BMI 21kg/m2 (SD1) 2.3% Low fruit and Intake daily 600g (SD50) 1.8% veg. Intake Inactivity Categories >2.5h/week, mod. 1.3% M. Ezzati et al. Lancet 2003;362:271-80 Global CVD

EPIDEMIOLOGIC TRANSTION Age Pestilence and famine Receding pandemics Degenerative “man-made” diseases Delayed degenerative diseases Predominant CVD Rheumatic heart disease Hypertension- related 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 Critchley J et al. Circulation 2004;110:1236-1244 Global CVD

CURRENT AND PROJECTED POPULATION PERCENTAGES FOR 2000, 2020 AND 2040 S. Leeder 2003

CVD IN AUSTRALIA: 11% TOTAL HEALTH SPENDING

USE OF MEDICATION IN STROKE AND CHD % WHO PREMISE project, 2002 Global CVD

ANTIHYPERTENSIVE DRUGS Available Affordable Locally manufactured 57% 67% 30% 48% 45% 91% 89% 74% 64% 7% 83% 46% 100% 96% 92% 88% 71% 70% Africa Americas Eastern Europe South-East Western Mediterranean Asia Pacific Percentage of countries in each region where drugs are available, affordable to low income groups, or manufactured locally WHO 2001 Global CVD

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) BP Three agents, 11 mmHg 46 (39-68) 63 (55-70) half dose DBP Platelet funct. ASA (75mg) Not quant. 32 (23-40) 16 (7-25) Homocysteine Folic acid, 3 μmol/L 16 (11-20) 24 (15-33) (0.5mg) Combined All 88 (84-91) 80 (71-87) BMJ, 28 June 2003 Polypill

FIVE-YEAR HARD CHD EVENTS Deciles based on Framingham function 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% 76% 65% 39% Percentage of countries with integration of components of NCD prevention and control programmes in primary health care WHO 2001 Global CVD

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