DECLARATION OF CONFLICT OF INTEREST. None

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1 DECLARATION OF CONFLICT OF INTEREST None

2 Dietary changes and its influence on cardiovascular diseases in Asian and European countries Problems of Eastern European countries for cardiovascular disease prevention Prof. Dr. Maria DOROBANTU, FESC, FACC CARDIOLOGY CLINICAL EMERGENCY HOSPITAL BUCHAREST, ROMANIA

3 CVD- the problem o 4.3 million deaths in Europe and over 2.0 million deaths in the EU o ½ of all deaths in Europe ; main cause of death and of the disease burden in Europe o At present, CVD mortality is about twice as high in Eastern Europe compared to the West (465/100,000 vs. 217/100,000)

4 B. Neal et al, Eur Heart J Supplements 2002; 4 (Suppl F): F2 F6

5 Source: European Cardiovascular Disease Statistics, 2008

6 Epidemiology of CVD Developed countries: decreasing tendencies Improvement of lifestyle factors and a higher level of health consciousness in many developed countries Better diagnostic and therapeutic procedures Developing countries: increasing tendencies Increasing longevity, urbanization and western type lifestyle

7 CVD mortality, incidence and case fatality are falling in most Northern, Southern and Western European Countries but either not falling as fast or rising in Central and Eastern European countries

8 Austria Denmark Finland France Greece Italy Netherlands Spain Switzerland United Kingdom Source: WHO HFA database EU-15 average

9 Croatia Hungary Romania Russian Federation Slovakia EU-15 average (MSs prior ) Source: WHO HFA database

10 Risk factors Over 300 risk factors have been associated with coronary heart disease, hypertension and stroke Approx. 75% of CVD can be attributed to conventional risk factors Risk factors of great public health significance: high prevalence in many populations great independent impact on CVD risk their control and treatment result in reduced CVD risk

11 WORLD Attributable Mortality in 2000 by Selected Leading Risk Factors * Number of Deaths (in thousands) IBLF dialogue with WHO. London.October.2002

12 European epidemiological studies international (EUROASPIRE, EUROHEART, GOOD Survey, BP Care study) national (e.g. France, Germany, Spain, UK, Czech rep., Hungary, Romania)

13 Source: European Cardiovascular Disease Statistics, 2008

14 EUROASPIRE Prevalence of Hypertension in High Risk Subjects 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% * SBP/DBP 140/90 mmhg for non-diabetics or 130/80 mmhg diabetics S2 vs. S1 : P=0.99 S3 vs. S2 : P=0.30 S3 vs. S1 : P=0.30 P=0.49 0% Czech Rep. Finland France Germany Hungary Italy Netherlands Slovenia ALL Survey % 59.0% 51.4% 60.7% 57.2% 57.6% 56.3% 59.2% 58.1% Survey % 55.7% 60.7% 69.5% 45.5% 54.7% 56.9% 68.4% 58.3% Survey % 71.3% 56.3% 55.0% 55.5% 63.9% 63.4% 58.7% 60.9% EUROASPIRE Study Group, Journal of Cardiovascular Risk, 2009

15 The Global CardiOmetabOlic risk profile in patients with hypertension Disease Belgium Germany Hungary Italy Netherlands Norway Portugal Slovenia Spain Sweden Turkey UK GOOD investigators: S.E. Kjeldsen, C. Farsang, S. Perlini, L. Naditch-Brule, W. Zidek

16 Diabetic population ANALYSIS BY REGION Northwest (N=574) Mediterr anean (N=1149) Atlantic European Mainland (N=521) Central Europe (N=950) SBP mmhg 142 (1.4) 143 (0.9) 143 (1.2) 141 (0.8) 0.43 DBP mmhg 82 (0.7) 83 (0.5) 82 (0.7) 83 (0.5) 0.68 PulseP mmhg 60 (1.1) 60 (0.8) 60 (1.0) 58 (0.7) 0.35 p Non-diabetic SBP mmhg 143 (0.8) 142 (0.6) 148 (0.9) 137 (0.7) < DBP mmhg 86 (0.5) 85 (0.3) 86 (0.5) 83 (0.4) < PulseP mmhg 57 (0.6) 57 (0.4) 61 (0.7) 55 (0.6) < Controlled 29.5% 30.8% 20.1% 29.5% < DurationHTy 8.4 (0.3) ) 7.7 (0.3) ) Farsang,C. et al.. J. Hum. Hypertens. 2009; 23,

17 Source: European Cardiovascular Disease Statistics, 2008

18 Prevalence of Raised Total Cholesterol (1)* 100% P< % 80% 70% 60% 50% 40% 30% 20% 10% 0% Czech Rep. Finland France Germany Hungary Italy Netherlands Slovenia ALL Survey % 83.3% 84.8% 84.1% 89.0% 92.5% 91.2% 89.0% 87.0% Survey % 42.6% 60.2% 66.3% 60.2% 56.9% 44.3% 68.3% 59.6% Survey % 14.5% 25.5% 28.4% 40.2% 30.7% 18.2% 25.5% 28.5% * Total cholesterol 5.0 mmol/l S2 vs. S1 : P< S3 vs. S2 : P< S3 vs. S1 : P< EUROASPIRE Study Group, Journal of Cardiovascular Risk, 2009

19 By 2025 the number of people with diabetes is expected to rise by 20% in Europe 50% in North America 75% in the Western Pacific 85% in South and Central America. For developing countries, there will be a projected increase of a 170% of cases; For developed countries, there will be a projected rise of 42%. Diabetes is the fourth main cause of death in most developed countries.

20 Diabetes Atlas second edition, IDF 2003

21 EUROASPIRE Prevalence of Diabetes* 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Czech Rep. Finland France Germany Hungary Italy Netherlands P=0.004 Slovenia ALL Survey % 15.4% 16.7% 13.5% 26.6% 17.2% 10.3% 17.4% 17.4% Survey % 18.7% 27.5% 13.5% 21.1% 21.8% 13.2% 23.8% 20.1% Survey % 19.1% 34.2% 22.6% 44.8% 21.7% 20.6% 18.8% 28.0% * Self-reported history of diagnosed diabetes S2 vs. S1 : P=0.21 S3 vs. S2 : P=0.02 S3 vs. S1 : P=0.001 EUROASPIRE Study Group, Journal of Cardiovascular Risk, 2009

22 Yugoslavia Greece Romania Czech Rep. England Finland Germany Scotland Slovakia Portugal Spain Denmark Belgium Sweden France Italy Netherlands Norway Hungary Switzerland % BMI 30 Source: IOTF 2003

23

24 SEPHAR STUDY Combinations of risk factors Other (under 2%) 16% None 14% Smoker 8% HBP+Obesity+Dislipi demia+insulinresistanc e 6% Obesity 9% HBP+Obesity+Smok er 3% Obesity+Dislipidemia +Smoker+Resistenc e to Insulin 3% HBP+Obesity 8% HBP+Obesity+Dislipi demia 7% Obesity+Smoker 4% Obesity+Dislipidemia +Resistence to Insulin 5% Dislipidemia+Smoker 2% HBP+Smoker 2% Obesity+Dislipidemia 5% Dislipidemia 4% HBP 4% Dorobantu, M. et al. Journal of Internal Medicine, 2006, SEPHAR study

25 SEPHAR STUDY Metabolic Syndrome Distribution Within the Sample No Metabolic Syndrome 79% Metabolic Syndrome 21% 3 Criteria 14% 4 Criteria 6% Dorobantu, M. et al. Journal of Internal Medicine, 2006, SEPHAR study 5 Criteria 1% Base: All respondents (2017)

26 Genes load the gun. Lifestyle pulls the trigger. Dr. Elliot Joslin

27 Changing economy Affluence Mass media Obesity Diabetes Hyperlipidemia Ischemic Stroke MI Cigarette smoking Reduced physical activity Increased caloric intake More meat consumption

28 Sanitation water quality Immunization Antibiotics Population growth Older population Increased salt intake Increased mechanization of food production More processed food Hypertension Hypertensive heart disease Hemorrhagic stroke

29 Large and increasing global burden of cardiovascular disease especially in developing countries. Cardiovascular disease prevention programmes almost all of the available comes from developed countries. Implementation of cardiovascular disease prevention programmes in developing countries is now required. Such programmes have great potential to impact on the current and projected epidemic of cardiovascular disease in those countries

30 More educated public Increased spending on medical care Secondary prevention practices Primary prevention practices Improved survival from MI Reduced MI, stroke at young ages

31 BP-CARE Study 2008 Participating Countries Latvia Belarus Czech Republic Slovakia Ukraina Romania Bosnia Serbia Albania Grassi,G. et al. Eur.Heart.J. 2010

32 BP-CARE Study 2008 Treated Patients (%) with BP Control Average values % % Control rate: 27.1 % < 140/90 mmhg 140/90 mmhg Grassi,G. et al. Eur.Heart.J. 2010

33 Percentage of patients displaying office blood pressure values Grassi,G. et al. Eur.Heart.J. 2010

34 SEPHAR Study TREATMENT AND CONTROL OF HYPERTENSION IN ROMANIA Treated Non treated Uncontrolled Controlled 93% 61% 39% 7% Dorobantu, M. et al. Journal of Internal Medicine, 2006, SEPHAR study

35 EUROASPIRE Control of Hypertension 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% * SBP/DBP < 140/90 mmhg for non-diabetics or < 130/80 mmhg for diabetics S2 vs. S1 : P=0.98 S3 vs. S2 : P=0.36 S3 vs. S1 : P=0.37 P=0.57 0% Czech Rep. Finland France Germany Hungary Italy Netherlands Slovenia ALL Survey % 39.1% 47.9% 39.7% 44.0% 41.0% 43.3% 37.7% 41.0% Survey % 43.4% 36.7% 29.1% 55.0% 45.7% 43.5% 31.1% 41.2% Survey % 29.1% 44.1% 45.2% 44.1% 34.8% 35.3% 41.4% 38.7% EUROASPIRE Study Group, Journal of Cardiovascular Risk, 2009

36 EUROASPIRE Therapeutic Control of Total Cholesterol (1)* 100% 90% P< % 70% 60% 50% 40% 30% 20% 10% 0% Czech Rep. Finland France Germany Hungary Italy Netherlands Slovenia ALL Survey % 24.2% 21.6% 25.9% 19.0% 5.4% 19.0% 14.6% 19.5% Survey % 70.1% 44.0% 41.1% 48.4% 48.5% 65.7% 41.0% 48.8% Survey % 86.8% 78.1% 75.2% 67.1% 71.3% 84.4% 77.9% 75.3% * Total cholesterol < 5.0 mmol/l S2 vs. S1 : P< S3 vs. S2 : P< S3 vs. S1 : P< EUROASPIRE Study Group, Journal of Cardiovascular Risk, 2009

37 EUROASPIRE III PRIMARY CARE Participating countries UK Finland Germany Latvia Belgium Poland Slovenia Romania Spain Croatia Italy Bulgaria

38 EA III Coaching Primary Care Model a high risk patient-centered intervention, made by general practionners, trained by cardiologists, diabetologists and nephrologists to use ESC Prevention Kit & ESC Prevention Guidelines Courtesy to Prof. Dan Gaita

39 Study design prospective study of 18 months on 325 patients ( years old, 38.2% males), who took part in EuroAspire III Primary Care Romania high risk individuals (men and women) under 80 years, without a history of coronary or other atherosclerotic disease, identified by their drug treatment: - antihypertensive drug therapy and/or; - lipid-lowering drug therapy and/or; - diabetes therapies (diet and/or oral hypoglycemic and/or insulin) Courtesy to Prof. Dan Gaita

40 Lifestyle small changes... Visit I Visit IV p Healthy diet: -eating more fruit and vegetables <0.001* -reducing sugar <0.001* Weight reduction: -following dietary recommendations * Increased physical activity: -following specific exercise advice from a health or exercise professional -trying to do more general everyday physical activities <0.001* <0.001* Courtesy to Prof. Dan Gaita

41 A significant decrease of blood pressure was obtained! The reduction of blood pressure (BP) and pulse pressure (PP) is explained both by lifestyle intervention and optimal recommendation of anti-hypertensive drugs. Parameters Visit I Visit IV p SBP (mmhg) 146± ±11.7 <0.001 DBP (mmhg) 86.19± ±7,6 <0.001 PP (mmhg) 61.12± ± Values are presented as mean ± standard deviation Courtesy to Prof. Dan Gaita

42 TC & LDL reduction... Lipid profile has significantly improved throughout the preventive intervention. Parameters Visit I Visit IV p Total cholesterol (mg/dl) LDL cholesterol (mg/dl) HDL cholesterol (mg/dl) Triglycerides (mg/dl) ± ±42.26 < ± ±35.51 < ± ± * 140.0* 0.6 Courtesy to Prof. Dan Gaita

43 better socioeconomic conditions, better health care, evidence-based population strategies But the improvements occur gradually and are long term goals.

44 Instead of treating CHD EUR EUR EUR

45 20 EUR 5 EUR 7 EUR

46 Thank you!