1. Innovations in Management of Cardiovascular Disease for Global Health
Elsayed Z. Soliman MD, MSc, MS
Epidemiological Cardiology Research Center (EPICARE)
Wake Forest School of Medicine, Winston Salem, NC
2011 Global Health Conference- Montreal, Canada
November 13, 2011

2. Outline Global burden of CVD Paradigm shift in concepts Applications
Public health approach vs. high risk strategy
Individual vs. global (total) CVD risk assessment/management
Applications
WHO/ISH risk prediction charts
Polypill
The objectives of this presentation are 1) To discuss how our current concepts of CVD prevention have evolved overtime, and 2) to discuss two applications of these current concepts

3. Distribution of major causes of death
WHO 2011

4. 17.3 million people died from CVDs in 2008
Global burden of CVD
17.3 million people died from CVDs in 2008
80% of CVD deaths take place in low- and middle-income countries
23.6 million expected to die from CVD By 2030
WHO 2011

5. Meeting the challenge
Life saving interventions are available, but the challenge is to increase its use by enhancing:
Availability
Affordability
Adherence
Sustainability
A paradigm shift in concepts is needed!!!

6. Public health approach vs. high risk strategy
Prevention paradox:
“An intervention which brings much benefit to population brings little benefit to individual and inversely”
Rose G. 1995

7. High Risk Strategy Population Strategy ...
A combination of population wide and high risk strategies are required to shift the CVD risk distribution of populations to more optimal levels
WHO publications

8. Global risk assessment
An assessment of total (global) risk based on the sum of all major CVD risk factors can be useful for:
(1) Identification of high-risk patients who deserve immediate attention and intervention
(2) Motivation of patients to adhere to risk-reduction therapies
(3) Modification of intensity of risk-reduction efforts based on the total risk estimate
Multifacorial disease requires multifactorial approach (AKA Global assessment/management )
Grundy et al. Circulation doi: /01.CIR

9. Global risk assessment: WHO CVD risk predication charts
Indicates total 10-year risk of a fatal or non-fatal CVD events, based on: age, sex, blood pressure, presence or absence of diabetes, smoking status, and cholesterol level (if available)
Geographic region-specific

11. Global vs. individual CVD risk management
Major cardiovascular (CV) risk factors, such as hypertension, dyslipidemia, obesity, and diabetes mellitus, often cluster within individual patients, dramatically increasing cardiovascular disease (CVD) risk
Source: Global Health Risks: Mortality and burden of disease attributable to selected major risks. WHO 2009 11

12. Global vs. individual CVD risk management
Any major risk factor, if left untreated for many years, has the potential to produce cardiovascular disease (CVD).
Neaton JD et al Arch Intern Med. 1992;152:56-64 12

13. Global risk management Polypill
A combination of multiple CVD drugs in one pill
Proponents:
Tackles multiple risk CVD factors
Addresses adherence
Expected to be inexpensive
Opponents:
Concerns about individualized medicine
Negative impact on lifestyle
Traditionally, drug therapy to prevent or treat CVD has focused on individual risk factors. However, treating individual risk factors in isolation is suboptimal for CVD prevention and treatment. Managing multiple CV risks with multifaceted therapy aimed at global CV health is an essential component of the management paradigm
BMJ 206:141903;32 13

14. Global risk management Polypill
Wald and Law proposed Polypill strategy
Combination of statin, thiazide diuretic, β blocker, ACE-I, folic acid and aspirin
To be given to everyone above the age of 55 years
No need for risk factor monitoring
88% estimated reduction in CHD and 80% in stroke
Current Polypill strategies:
Exclude folic acid
Not for everyone
Estimated effect on risk reduction is less than that of Wald and Law 14

15. Polypill efficacy TIPS- Indian Polycap
Indian Polycap Study (TIPS) investigators. Lancet 2009;373:1341–1351.

16. Polypill acceptability WHO-sponsored Sri-Lanka pilot study
Patient acceptability
203 patients who completed the study and 207 who were screened but deemed ineligible to be enrolled
Approx. 90% of the patients who completed the study indicated that they would "definitely" or "probably" take the pill for life if it were shown to be effective in reducing CVD risk
A similar response level (89%) was obtained from those who were screened but found to be ineligible for the study
Soliman et al (Trials 2011).

17. Polypill acceptability WHO-sponsored Sri-Lanka pilot study
Physician acceptability
84 physicians from the participating clinical sites and the Council of General Practitioners in Sri Lanka
86% would prescribe it for primary prevention
93% would prescribe it for secondary prevention
Results did not vary by specialty
Soliman et al (Trials 2011).

18. Polypill acceptability USA physicians
Similar acceptability rates in the US
Preventive Medicine 2011

19. Summary CVD is a major global health issue
A combination of population wide and high risk strategies are required to shift the CVD risk distribution of populations to more optimal levels
There is a call for a paradigm shift from assessment and treatment of risk factors in isolation, to a comprehensive CVD risk assessment and management approach