Contribution of NCD and CVD to the Global Mortality and GBD in 1998 (LIC & MIC)

Transcription

1 Contribution of NCD and CVD to the Global Mortality and GBD in 1998 (LIC & MIC) Disease Contrib of NCD s to total global mortality (%) LIC + MIC Contrib to global NCD mortality (%) Contrib of NCD s to total burden of disease (%) LIC + MIC Contrib to NCD burden of disease Total NCD (%) CVD million deaths annually in the world One third are from CVD

2 PURE: 663 communities in 22 countries from 5 continents Canada - 82 Poland - 4 Sweden - 31 Turkey - 44 Colombia - 58 Palestine - 39 Saudi- 18 UAE-3 Iran - 20 Pakistan - 4 China India - 90 B desh - 56 Philippines - 2 Brazil - 14 Tanzania - 19 Malaysia - 71 Zimbabwe - 3 Chile - 5 Argentina - 20 South Africa - 8

3 Prospective Urban Rural Epidemiologic (PURE) Study 155,000 (200,000+) adults from 17(25) countries (LIC, MIC, HIC) Urban and Rural 600(900) communities Societal level influences (Socioeconomic, tobacco & other health policies, relative food prices and availability, built environment, indoor/outdoor pollution) Lifestyle behaviours X genes Individual risk factors CVD, DM, Obesity, Cancers,Obstructive Airways Disease,Renal dis,injuries.

4 PURE: INTERHEART Risk Score Yusuf et al NEJM 2014

5 CVD Event Rates Major CVD = death from CV causes, stroke, MI and HF Non major CVD = all other CVD events that led to hospitalization Yusuf et al NEJM 2014

6 Prevalence of hypertension awareness, treatment and control in 18 countries (154,000 people) Aware

7 Use of 2 + BP lowering Meds

8 Proven Drugs in secondary prevention Yusuf et al Lancet 2011 Antiplatelet Agents Beta Blockers % ACE Inhibitors or ARBs Statins

9 Prevalence awareness, treatment and control of hypertension

10 % receiving proven medication with CHD or Stroke

11 % receiving proven medication with CHD or Stroke

12 Interventions with Clear Evidence 1. Tobacco avoidance 2. Hypertension control 3. Secondary prevention Approach: Identify gaps & barriers and make these interventions impactful (legal, societal and health systems framework + affordable + efficient delivery mechanisms)

13 Number (%) of Major or All CVD for Different Sub-Groups in PURE (n=152,609) Baseline Condition Total no. with Condition (%) Follow-up Major CVD N = 3,488 (2.23 %) CVD 7,743 (5.1) 673 (19.3) Hypert (History or 140/90) 62,034(40.7) 2,317 (66.4) Current Smoker 31,397 (20.6) 1,021 (29.4) CVD, Hypert or Smoker 84,078 (55) 2,822 (80.9) Diabetes(History or FPG >7mmol) CVD, Hypert, Smoker or Diabetes 16,071(10.5) 905 (26.0) 88,326 (57.9) 2,929 (84.0)

14 Availability of the 4 medications by country income group N communities: *Availability of at least one ACE-Inhibitor, beta blocker, statin, and an aspirin Khatib PURE In Press Lancet

15 Monthly cost of 4 CVD medications as a percentage of households capacity-to-pay(pure,in press Lancet) Urban Rural Urban Rural Urban Rural Urban Rural Urban Rural HIC UMIC LMIC LIC ex. India India Statins Beta blockers ACE-inhibitors Aspirin

16 Steps Towards Developing a Global Evidence Based CVD Control Policy 1. Identify and focus on interventions with high quality and robust evidence 2. Being Parsimonious (biggest bang for the least effort) 3. Gaps and identifying barriers 4. Overcoming barriers and developing feasible and cost-effective strategies 5. Implementing action plans that are contextually appropriate

17 Road maps: Approach Situation analysis: Need national health surveillance observatories Barriers to prevention or treatment Implement cost effective strategies to overcome barriers/road blocks Re-measure situation Continuous improvement and measurement

18 Road maps 5 Overview articles in Global Heart June 2015: Overview and editorial comments. Secondary Prevention Hypertension control Tobacco control Contextualizing by country or region. WHF website as a resource to develop local tools and website

19 Barriers along Hypertension Detection in Malaysia (1) First high BP reading: Little routine monitoring, patients not aware of need to chk BP. Detection of hypertension at community outreach activities, so difficult to follow. Second BP reading and diagnosis: Patients in denial, do not return to clinic for follow-ups Clinic staff do not have time to full counsel patient, no education or awareness material available, staff inadequately trained Repeat visit entails costs, travel & time off work for pt /relative

20 Barriers along Hypertension Patient Pathway in Malaysia (2) Check-up and follow-up appointments: Little time to counsel patients, insufficient staffing. No register to trace defaulting patients Long waiting times, limited patient-doctor interaction discourages patients from attending clinic, patients visit various health clinics--- so no continuity of care Pts have difficulty attending clinics due to distance, time off from work, need for relative to accompany them & transport issues Medication: Prescriptions given for only one month, patients do not have time to return each month. Pts non-adherent for cultural or personal reasons Pts supplement their HT medication with traditional or complementary medicine Pts have side effects from first-line drugs and stop taking medication

21 Barriers along Hypertension Patient Pathway in Malaysia (3) Lifestyle Modifications: Clinic staff inadequately trained or resourced. Patient education or awareness material poorly developed or not available No social support Patients are overwhelmed by poor diet options Risso-Gill. BMC-Health Services Res 2015

22 Reducing the Evidence- treatment gap Document context specific systems and cultural barriers in each region, country & community Systematic screening for hypertension and for known CVD using NPHW. Use low dose FDC (polypill) --- ease of prescription and use, improved adherence, lower costs and potential large reductions (50-75% RRR) in CVD and mortality.

23 SODIUM INTAKE AND BP (META- ANALYSES OF RCTS) Description Trials n BP (mmhg) Aburto et al BMJ 2013 All /1.54 Hypertensive /2.26 No HTN /0.58 < 3 months / months /1.33 >6 months /0.45 (NS) Graudal et al Adv Nutr 2015

24 SODIUM INTAKE AND MORTALITY + CVD Australian DM Study (n=638; 24-h) Thomas et al Diabetes Care 2011 SURDIAGENE (n=1437; DM, EMU) Saulnier et al NEJM 2014 PURE Study NEJM 2014 (n=101,945; EMU) ONTARGET/TRANSCEND JAMA 2011 (n=28,880; EMU) EPIC-Norfolk (n=19857; USE, 12.9 y) Pfister al EHJ 2014 Health ABC (n=2642; FFQ, 10 y) Kalogeropoulos et al JAMA-Int Med 2015

25 RENIN & ALDOSTERONE Increased Renin, Aldosterone, catecholamine (at Na intake <2.3g/day) 3.6 vs 2.3 g/d 70% increase in PRA Brunner et al NEJM 1972

26 RECOMMENDATION ON ESSENTIAL NUTRIENT (IOM) Heaney R AJH 2013

27 Road map for Hypertension Situation analysis: Prevalence, awareness, treatment ( 1, 2 or 3 + drugs) and control Measure barriers : a) adequate to measuring BP ( staff, facilities, functioning equipment) b) How often is BP measured in adults ( what is practical and optimal? Opportunistic screening) c)knowledge of patients and health staff about elevated BP : risks, how to measure BP, how to reduce it, importance

28 Road map for hypertension (2) d) barriers to care (access to clinics, trained and adequate nos of staff, reliable availability and affordability of drugs, advice on lifestyle ( esp smoking cessation) e) Audits of care & adherence ( hosp, community) f) re-measure impact (prevalence, awareness, treatment and control rates) every 3 to 5 yrs in the community g) added interventions: smoking cessation, diet, activity, lipid interventions h) measure impact on CVD:( stroke, MI, HF, deaths)

29 Road maps for secondary prevention 1.Measure prevalence of self reported CVD, use of ASA( clopidogrel), ACE-I,BB and statins and smoking rates 2.Local Knowledge and barriers :( systems, health care and patient levels) assessments 3. Programs to improve secondary prevention ( implantation & adherence) 4.Re- measure use of key meds and smoking cessation in clinics and communities 5. Impact on CVD and mortality

30 Road map for tobacco control Situation analysis: Prevalence of types of tobacco use, attitudes, knowledge about harms and how to quit, laws & their implementation Barriers: Easy availability and low cost, marketing to children and adults, poor enforcement of laws, interference from tobacco industry tactics,inadequate health and safety warnings on packets

31 Road maps for tobacco control(2) Barriers: low govt priority, inadequate resources for implementation and monitoring ( laws, implementation and tobacco use rates),poor intersectoral co-operation, no tobacco cessation training or programs and low priority, low taxes on tobacco

32 Males: Age Standardized IHD Mortality/ 100,000 persons by Region and Globally, , the GBD 2010 study Moran et al, Circulation In press

33 An RCT of an Integrated low cost model for CVD Prevention (HOPE 4) Door to door screening by trained NPHW of BP, vasc disease, self reported risk factors (diabetes, smoking, activity, diet, alcohol), BMI or WC to use a non-lab risk score to identify hi risk people LS advice + initiate combo drugs for HTN & secondary prev+ moderate or hi risk. Very hi risk people/those with side effects referred to clinics Follow up in homes by NPHW to reinforce adherence to LS and drugs. Use patient supporters Tel link with physicians to use drugs and advice Pilot initiated in Malaysia, Columbia & Canada

34 Conclusions 1. Implement what is clear: tobacco & hypertension control, secondary prevention, Med type diet, improved physical activity. 2. Emphasis on areas that are not clear is a distraction, may be adverse, wasteful, or not feasible (e.g. decreasing Na to very low levels) 3. Need for health systems approaches to overcome barriers and reducing the Evidence-Prevention/Treatment Gap 4. Focus on developing implementation strategies (e.g. Roadmaps), capacity building (e.g. Emerging Leaders, capacity in primary care), objective review of evidence (e.g. Diet workshop ) to facilitate an evidence based approach to CVD prevention

35 Final words It is the simple things that will make the BIG difference as it will help a LOT of people! They may not be sexy or politically savvy, but they will save many, many more lives than the very hi tech approaches & at lower costs. By achieving the goals of 25 X 25, we will avoid 12.5 mill (of which 1/3 is from CVD) premature deaths ( and twice as many morbid events ) every year in the world!