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 High BP Tobacco High cholesterol High BMI Low fruit and veg. Intake Inactivity Exposure Variable Usual SBP Smoking impact ratio; oral tobacco use Usual TC BMI Intake daily Categories Theoretical Minimum 115mmHg (SD6) No use 3.8mmol/L (SD0.6) 21kg/m2 (SD1) 600g (SD50) >2.5h/week, mod. Contribution to GBD 4.4% 4.1% 2.8% 2.3% 1.8% 1.3%

Global CVD

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

•Hypertension•related •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 25 20 15 10 5 0

% population 65+

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% Pharmaceuticals 26% 4% 4% Aged care

GPs Imaging & pathology

Out-of-hospital specialists

USE OF MEDICATION IN STROKE AND CHD
Aspirin St t ains
9 6 7 9 8 1 6 6 5 8 3 8 2 9 9 3 8 2 8 1 6 2 3 2 8 7 8 8 9 7 8

% 100
9 0 8 0 7 0 6 0 5 0 4 0 3 0 2 0 1 0 0 Brazil Egypt 6 6 8 3

9 5

3 1

India

Indone sia

Iran, P akistan Sri Lanka Turke y Russian Tunisia Islam ic Fe ration de R public of e

Global CVD

WHO PREMISE project,

ANTIHYPERTENSIVE DRUGS
Available Affordable ocally manufactured L
57% 48% 7% 46% 70% 88% 92% 74% 45% 64% 100% 71% 67% 91% 83% 96% 30% 89%

Africa

Americas Eastern Europe South-East Western Mediterranean Asia Pacific

entage of countries in each region where drugs are availabl rdable 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 BP Platelet funct. Homocysteine Combined Agent Statin Three agents, half dose ASA (75mg) Folic acid, (0.5mg) All Reduction 1.8 mmol/L 11 mmHg DBP Not quant. 3 μmol/L IHD 61 (51,71) 46 (39-68) 32 (23-40) 16 (11-20) 88 (84-91) Stroke 17 (9-25) 63 (55-70) 16 (7-25) 24 (15-33) 80 (71-87)

Polypill

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

Am rica e s

Ea e st rn Europe M dit rra a e e ne n

Sout h-Ea st Asia

W st rn e e Pa cific

ountries with integration of components of NCD prevention rammes 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