Cardiovascular diseases and risk factors Chronic respiratory disease

1. Noncommunicable Diseases - Cardiovascular Disease and Chronic Respiratory Disease ; Issues for National Program Managers Dr Shanthi Mendis MBBS MD FRCP FACC Coordinator, Chronic Disease Prevention & Management World Health Organization Geneva Switzerland

2. Cardiovascular diseases and risk factors • Chronic respiratory disease • Integrated approach to addressing NCDs • National program

3. Integrated NCD Policy • National Health agenda • National development agenda • Monitoring and evaluation • Advocacy/HE • Reducing risk factors • Health systems/PHC • Implementation research • Intersectoral collaboration /Community National Program

4. The rapidly increasing burden is in developing countries Greatest increase in EMR, SEAR and AFR % of Premature deaths are higher in LMIC

5. Cardiovascular Diseases and risk factors Coronary heart disease Cerebrovascular disease Hypertension (diabetes, behavioural and other RF) Congenital heart disease (prevention and surgery) Rheumatic heart disease Peripheral vascular disease Arrhythmias (elderly AF…/stroke…) Cardiomyopathies (HOCM, nutritional, viral) Others

6. Chronic Respiratory Disease Bronchial asthma Chronic obstructive pulmonary disease Occupational lung disease (Tobacco, air pollution (indoor and outdoor)

7. What are the major noncommunicable diseases ?

8. Multifaceted interventions SocialDeterminants of Health

9. Social determinants • Diabetes, tobacco • Renal disease • Mental Health • Bronchial carcinoma • Tuberculosis • Sleep apnoea • Allergic rhinitis • Prenatal • Maternal and child health • Elderly • Oral and eye health Links to other programs

10. Atherosclerosis Cardiovascular disease Stroke Myocardial infarction Globalization, Ageing, urbanization Tobacco, alcohol, unhealthy diet (salt and fat), physical inactivity, Obesity, diabetes, hypertension, hypercholesterolemia, Albminuria, poverty Haemorrhagic, thrombotic

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

12. 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

13. Primodial prevention • Primary prevention • Secondary prevention • Stroke (care, units) • Acute MI • CABG • PCTA/Stents CVD

14. Screening of RF • Screening for disease • Hypertension and diabetes • Clustering of RF • Incubation period Screening CVD / Diabetes

15. 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

17. Between 2010 and 2015 there will be an increase of 15%

18. Per capita expenditure on health (International dollars ) Expenditure Number of countries 33 25 72 24 19 18 Less than 50 $ 50 – 99 100-499 500-999 1000-1999 >2000

19. (see CVD Atlas 2011)

20. US$ 170B is the overall cost for all developing countries to scale up action by implementing a set of "best buy" interventions, identified as priority actions by WHO What is new? The cost of action vs inaction estimated Over the next fifteen year (2011-2025) US$ 7 Trillion is the cumulative lost output in developing countries associated with NCDs between 2011-2025

21. Best Buys Feasible, affordable, high impact Pro poor Cancer of cervix Treatment of pre-cancer and Hepatitis B immunization

22. Global Price Tag for scaling-up NCD 'best buys' in developing countries US$11.4 billion/year 16 14 12 10 8 6 4 2 0 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2 billion 9.4 billion Cost (US$ billion) "Best buy" population-based interventions for NCD risk factors (tobacco, alcohol, diet, physical activity) "Best buy" individual-based interventions for NCDs (cardiovascular disease, diabetes, cancer)

23. How much will it cost to scale-up NCD 'best buys'? • Population-based measures: close to US$ 2 billion per year • Low- and lower-middle-income countries: < US$ 0.20 per head • Upper-middle income countries: < US$ 0.50 per head • Individual-based measures: US$ 9.4 billion per year • Low-income countries: < US$ 1.00 per head • Lower middle-income countries: < US$ 1.50 per head • Upper-middle income countries: ~ US$ 2.50 per head

24. Prevent/protect Detect cases early Diagnose and treat Follow up cases Treat Emergencies Noncommunicable diseases and PHC Prevent premature death Improve adherence Improve health outcomes Reduce costs Reduce complications Reduce admissions to hospitals

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

26. 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 Primary Health Care

27. 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

28. BPMD and BP 140/90, 130/80, 120/80 • Glucometers - Point of care devices can be used in diagnosing diabetes if laboratory services are not available. • FBG ≥7.0mmol/l (126mg/dl) or 2 hour PG ≥11.1mmol/l (200mg/dl) Diagnosis

29. HbA1c can be used as a diagnostic test for diabetes, provided that stringent quality assurance tests are in place and assays are standardised to criteria aligned to the international reference values, and there are no conditions present which preclude its accurate measurement. • An HbA1c of 6.5% is recommended as the cut point for diagnosing diabetes. A value less than 6.5% does not exclude diabetes diagnosed using glucose tests. • There is insufficient evidence to make any formal recommendation on the interpretation of HbA1c levels below 6.5%. HbA1c

30. Statins • Antihypertensives • ACEI • CCB • Thiazides • Metformin • Insulin Medicines

31. Low-dose thiazides or ACE inhibitors are recommended as first-line treatment of hypertension in diabetic patients. They can be combined. • . Beta blockers are not recommended for initial management of hypertension in diabetic patients, but can be used if thiazides or ACE inhibitors are unavailable or contraindicated. • BP <130/<=80 Antihypertensives

32. Risks are increasing (2030 horizon) (WHO, 2008)

33. Chronic Respiratory Diseases

34. Source: World Health Report, 2002

35. Source: World Health Report, 2002

36. Blood pressure Tobacco Tobacco Alcohol Cholesterol High Body Mass Index Fruit and vegetable intake Physical inactivity Illicit drugs Lead exposure Unsafe sex Iron deficiency Occupational risk factors for injury Urban air pollution Urban air pollution Childhood sexual abuse Underweight Unsafe water, sanitation, and hygiene Indoor smoke from solid fuels Number of Disability-Adjusted Life Years (000s) EUROPE 2000 attributable to selected risk factors Europe - DALYs attributable to selected risk factors (2000) 0 5000 10000 15000 20000

37. Unsafe sex Underweight Unsafe water, sanitation, and hygiene Vitamin A deficiency Zinc deficiency Indoor pollution Indoor smoke from solid fuels Iron deficiency Alcohol Blood pressure Lack of contraception Tobacco Tobacco Cholesterol Unsafe health care injections Global climate change Occupational risk factors for injury Fruit and vegetable intake 0 10000 20000 30000 40000 50000 60000 70000 Number of Disability-Adjusted Life Years (000s) AFRICA Disease burden (DALYs) in 2000 attributable to selected risk factors Lead exposure

38. Previous diagnosis • Symptoms since childhood or early adult hood • Hayfever, eczema, allergies • Intermittent with asymptomatic periods • Symptoms worse at night and early morning • Triggered by weather changes, infection, exercise stress • Respond to salbutamol • Before and 15 mt after 2 puff of salbutamol PEF improves 20% Asthma

39. Daytime symptoms salbutamol 2 or less per week • Night time symptoms 2 or less per month • No or minimal limitation of daily activities • No admission to hospital or oral steroid need in a month • PEF above 80% predicted Asthma control

40. Inhaled salbutamol PRN • Above plus beclomethasone • Low dose oral theophylline (if no longacting beta agonists) • Oral prednisolone Asthma Treatment

41. Poor control • Diagnosis uncertain • Regular oral prednisolone needed Referral

42. Previous diagnosis • Heavy smoking • Exposure to fossil fuels or occupational dust • Symptoms after 40 years • Symptoms worsened slowly over time • Cough with sputum • Symptoms persistent COPD

43. Inhaled salbutamol • If symptoms are still troublesome • Low dose oral theophylline • Ipratropium bromide • Stop smoking • Avoid indoor airpollution and dust Treatment

44. Thank You