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Mortality/Morbidity Incidence/Prevalence Primary prevention

Epidemiology, Burden and Primary Prevention of Cardiovascular Disease Dr Shanthi Mendis MBBS MD FRCP FACC Coordinator Chronic Disease Prevention and Management World Health Organization Geneva, Switzerland. Cardiovascular Diseases.

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Mortality/Morbidity Incidence/Prevalence Primary prevention

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  1. Epidemiology, Burden and Primary Prevention of Cardiovascular DiseaseDr Shanthi Mendis MBBS MD FRCP FACC Coordinator Chronic Disease Prevention and ManagementWorld Health OrganizationGeneva, Switzerland

  2. Cardiovascular Diseases Mortality/MorbidityIncidence/Prevalence Primary prevention

  3. Global magnitude of deaths from noncommunicable diseases 70 million 10% 60 million 5.8M 31% 35.0M 50 million 40 million 59% 30 million 20 million 18.0M Source: 10 million 0 Total number of deaths (2004) Group III - Injuries Low-income countries Group II – Deaths from noncommunicable diseases Group I – Communicable diseases, maternal, perinatal and nutritional conditions

  4. Global mortality Communicable maternal infant All other Non communicable diseases Cancer 13% 16% 40% Diabetes 29% (17 million) 2% cardiovascular diseases ( Three quarters of the burden in LMIC) 4

  5. Cardiovascular Diseases - CVD contributes 29% of global deaths - 88% of the global CVD burden is in LMICs -Total CVD deaths 17.1 million - 12.9 million deaths ( coronary heart disease deaths 7.2 million, cerebrovascular disease deaths 5.7 million ) due to atherosclerotic disease

  6. Cardiovascular Disease Burden (DALYs) Total 151 377 (10% GDB ) Africa 14 263 SEA 42 001America 15 217EMR 13 095Europe 34 760WPR 31 759

  7. Age standardized NCD burden by country income group (2004 Age-standardized NCD burden by country income group, 2004

  8. Noncommunicable Diseases (2006-2015) WHO projects that over the next 10 years, the largest increase in deaths from cardiovascular disease, cancer, respiratory disease and diabetes will occur in developing countries. (WHO, Chronic Disease Report, 2005)

  9. Cardiovascular mortality trends In high income countries CV mortality is declining In middle income countries CV mortality is high and rising In low income countries CV mortality will rise.

  10. Leading causes of burden of disease Leading causes of burden of disease, 2004 and 2030

  11. CVD • In 2002, the World Health Report , published the results of a global risk factor study conducted by WHO. • The aim was to quantify some of the most important risks to health • The list of 26 risk factors surveyed included cardiovascular risk factors. • > 75% of the global CVD burden was due to tobacco, blood pressure, cholesterol or a combination of the three

  12. Few risk factors account for the global burden of cardiovascular disease

  13. Blood pressure, stroke and IHD 8.00 8.00 4.00 4.00 2.00 2.00 Relative Risk & 95% CI 1.00 1.00 0.50 Stroke 0.50 IHD (-10 mmHg = -42%) (-10mmHg =- 24%) 0.25 0.25 110 120 130 140 150 160 170 110 120 130 140 150 160 170 Usual SBP (mmHg) Usual SBP (mmHg) APCSC J Hypertens, 2003

  14. CVD • WHOs Project for MONItoring of trends and determinants in CArdiovascular disease (MONICA) • Trends in CVD in 38 populations in 21 countries. • During the 10-year period covered by the MONICA Project, mortality from CHD and stroke reduced dramatically. • The greatest reduction 6.5% per year over a 10-year period in North –Karelia , Finland.

  15. CVD • Across all MONICA populations with declining CHD mortality, reduced incidence contributed to 75% of the change in men and 66% in women, the remainder being attributed to reduced case fatality. • For stroke, 33% of the changes were attributed to reduced incidence and two thirds to reduced case fatality. • The change in incidence reflected risk factor changes in the populations.

  16. CVD • Supported the findings of the Framingham study and the view that population-wide prevention strategies and strategies targeting people with disease or with high risk, are complimentary approaches for reduction of the burden of CVD

  17. Synergism of population-wide and high risk strategies Mendis S 2005

  18. CVD • The INTERHEART study ; case-control study of acute MI in 52 LMIC • Provided evidence that five established risk factors (tobacco use, lipids, hypertension, diabetes and obesity), which can be measured relatively easily, predict about 80% of the population attributable risk of AMI. • WHO estimates published in 2009, show that eight preventable risk factors (tobacco use, physical inactivity, raised blood pressure, raised blood glucose, raised blood cholesterol, alcohol use, high body mass index and low fruit and vegetable intake) account for 61% of total CVD deaths.

  19. Why are there economic consequences? • High health care budgets • Health care budgets will rapidly increase • Resources for other areas (education), suffer • Lost productivity due to premature mortality

  20. Primary Prevention

  21. Action Plan of the WHO Global Strategy Endorsed by the World Health Assembly in May 2008 by all Member States Six objectives: 1. Raising the priority accorded to NCD in development work at global and national levels 2. Establishing and strengthening national policies and programmes 3. Reducing and preventing risk factors 4. Prioritizing research 5. Strengthening partnerships 6. Monitoring NCD trends and assessing progress at country level

  22. CVD and salt • Positive association between salt and BP • Significant relationship between the rise in BP with age and salt intake • Systematic review (17 trials HBP and 11 trials with NBP) • Correlation between magnitude of salt reduction and BP reduction within the range 3-12 gm/day • Intensive interventions reduce BP significantly (DASH trial) • Individual efforts work in the short term, more difficult in the long-term (0.6 mm Hg diastolic, 1.1 mm Hg systolic)

  23. CVD and Trans-fat • Trans-fats (unsaturated fatty acids with that contain one or more isolated (non conjugated )double bonds in a trans configuration • Formed during partial hydrogenation of liquid vegetable oils resulting in semi solid fats used in margarines, cooking oils and bakery products • Stability during frying and long shelf life • Consumption may be 4.5 – 7 gms per day, 2-3% of total calories • Conclusive evidence that trans-fats increases the risk of CHD

  24. Reduce Trans-fat • Denmark, Canada, France, USA, Russia (labelling and regulation) • Argentina, Chile, Brazil , Paraguay, Uruguay • Significant reduction is feasible • Total elimination should be the goal • Less than 2% in cooking oils and <5% in other foods

  25. Cost to implement the package of interventions (US$ per person per year, 2005) Asaria et al, Lancet 2007;370:2044-2053

  26. Thank You

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