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

2. 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?

3. 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

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

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

6. 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

7. 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

8. 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

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

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

11. 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

12. 3. Why an integrated approach in PHC?

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

14. 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

15. 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

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

17. 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

18. 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

19. WHO/ISH charts Screen for risk of heart attacks and strokesG 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

20. 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

21. 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)

22. 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)

23. 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 years select age group box 50, if years select age group box 60, etc.; for people age < 40 years select age group box 40

24. 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 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 mg daily, enalapril 5-20 mg daily, atenolol mg daily, amlodipine 5-10 mg daily
Titrate oral agents until blood glucose level at target
Give simvastatin 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 mg daily
Give aspirin mg daily
Follow up every 3-6 months

25. 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

26. Thank You