Global burden of Cardiovascular Diseases
Andrew M Tonkin, MD
PROJECTED GLOBAL BURDEN OF CVD
30
CVD Deaths (millions)
25 20 15 10 5 0 1990 2020 5 9 19 6
Established market economies and former socialist economies of Europe Demographically developing countries
Global CVD
Deaths
B. Neal et al. Eur. Heart J 2002
GLOBAL BURDEN OF DISEASE: COMMON CVD RISK FACTORS
Risk factor Exposure Variable Theoretical Minimum Contribution to GBD
High BP Tobacco High cholesterol High BMI Low fruit and veg. Intake Inactivity
Global CVD
Usual SBP Smoking impact ratio; oral tobacco use Usual TC BMI Intake daily Categories
115mmHg (SD6) No use 3.8mmol/L (SD0.6) 21kg/m2 (SD1) 600g (SD50) >2.5h/week, mod.
4.4% 4.1% 2.8% 2.3% 1.8% 1.3%
M. Ezzati et al. Lancet 2003;362:271-80
EPIDEMIOLOGIC TRANSTION
Age Pestilence and famine Receding pandemics Degenerative “man-made” diseases CHD, stroke, diabetes at young ages 35-65 Delayed degenerative diseases CHD, stroke at older ages
Predominant CVD
Rheumatic heart disease
Hypertensionrelated diseases 10-35
% of deaths due to CVD
5-10
<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
30
% population 65+
25 20 15 10 5 0
S. Africa India Brazil China Russia Portugal U.S.
2000
2020
2040
S. Leeder 2003
CVD IN AUSTRALIA: 11% TOTAL HEALTH SPENDING
Total $6,563.7m
Inpatients 41% Outpatients 5% 5% 10% 6% 3% Research OHPs 1% 26% 4% 4% Aged care
GPs Imaging & pathology
Pharmaceuticals
Out-of-hospital specialists
USE OF MEDICATION IN STROKE AND CHD
Aspirin Statins
96 79 81 66 58 38 29 9 38 28 16 23 28 78 89 78
% 100
90 80 70 60 50 40 30 20 10 0 Brazil Egypt 66 83
95
31
India
Indonesia
Iran, Pakistan Sri Lanka Islamic Republic of
Turkey
Russian Tunisia Federation
Global CVD
WHO PREMISE project, 2002
ANTIHYPERTENSIVE DRUGS
Available Affordable
57% 48%
Locally manufactured
67%
45%
64%
30% 89%
91%
83% 100% 71%
7% 46%
70%
74%
88%
92%
96%
Africa
Americas
Eastern Europe Mediterranean
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 LDL-C Agent Statin Reduction 1.8 mmol/L IHD 61 (51,71) Stroke 17 (9-25)
BP Platelet funct. Homocysteine Combined
Polypill
Three agents, half dose ASA (75mg) Folic acid, (0.5mg) All
11 mmHg DBP Not quant. 3 μmol/L
46 (39-68) 32 (23-40) 16 (11-20) 88 (84-91)
63 (55-70) 16 (7-25) 24 (15-33) 80 (71-87)
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% 76% 65% 88% 88%
39%
Africa
Americas
Eastern Europe Mediterranean
South-East Asia
Western Pacific
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