Upload
others
View
8
Download
0
Embed Size (px)
Citation preview
Professor Shahryar A. SheikhWorld Heart Federation
17th Asian Pacific Congress of CardiologyKyoto, Japan20 May, 2009
Professor Shahryar A. SheikhWorld Heart Federation
17th Asian Pacific Congress of CardiologyKyoto, Japan20 May, 2009
Global Burden of Cardiovascular Disease
“CHALLENGES AHEAD”
Global Burden of Cardiovascular Disease
“CHALLENGES AHEAD”
Global Burden of Cardiovascular Diseases
Burden in the Asia Pacific Region
Risk Factors Prevalence and Trends
Major Challenge for the 21st Century
CVD Burden of Disease and Investment: The Great Disconnect
Is There Hope?
Call to Action
Global Burden of Cardiovascular Disease:Challenges AheadGlobal Burden of Cardiovascular Disease:Challenges Ahead
Noncommunicable diseases:Noncommunicable diseases: Infectious diseases:Infectious diseases:
Deaths by cause in the world (2005)Deaths by cause in the world (2005)
(WHO, Chronic Disease Report, 2005)
Heart disease30.2%
Cancer15.7%Diabetes1.9%Other chronic diseases15.7%
HIV/AIDS 4.9%
Tuberculosis 2.4%
Malaria 1.5%
OtherInfectiousDiseases
20.9%
Injuries 9.3%
Total58.2M
18 Million
Asian Contribution for Global Burden of CVDAsian Contribution for Global Burden Asian Contribution for Global Burden of CVDof CVD
Murray C J L and Lopez D The Lancet 1997; 349:1269
Sub-Saharan Africa10%
Latin American andCaribbean counties
7%India, China and other Asian Pacific Island countries
50%
Formerly socialist economies
8%
Established marketeconomies
14%
Middle Eastern8%
AsiaAsiaAsiaCountries: 46
Population: 3.8 billions60.5% world population
India and China have the highest number of deaths in the world from coronary heart disease
India and China have the highest number of deaths in the world from coronary heart disease
702 925
1 531 534
Source: WHO Atlas of Heart Disease and Stroke, 2004
A Threat to Socioeconomic DevelopmentProjected Foregone National Income due to
Heart Disease, Stroke and Diabetes
Brazil 2.7 49.2
China 18.3 557.7
India 8.7 236.6
Pakistan 1.2 30.7
Russian Federation 11.1 303.2
United Kingdom 1.6 32.8
US$ BillionUS$ Billion
Source: Preventing Chronic Disease: A Vital Investment, WHO 2005
2005200510 years
accumulated10 years
accumulated
Window of Opportunity for Prevention of CVDProjected deaths by cause and income
(2004 to 2030) WHO
Window of Opportunity for Prevention of CVDProjected deaths by cause and income
(2004 to 2030) WHO
HIV, TB, malaria
Other infectious
Mat//peri/nutritional
CVD
Cancers
Other NCD
Road traffic accidentsOther unintentionalIntentional injuries
0
5
10
15
20
25
30
2004 2015 2030 2004 2015 2030 2004 2015 2030
Dea
ths
(mill
ions
)
High income Middle income Low income
A Challenge and An OpportunityA Challenge and An Opportunity
The rapid rise of cardiovascular diseases represents one of the major health challenges to global development in the coming century. This growing challenge threatens economic and social development as well as the lives
and health of millions of people.
The rapid rise of cardiovascular diseases represents one of the major health challenges to global development in the coming century. This growing challenge threatens economic and social development as well as the lives
and health of millions of people.
There now exists, however, a vast body of knowledge and experience regarding the preventability of such diseases and immense opportunities of global action
to control them.
There now exists, however, a vast body of knowledge and experience regarding the preventability of such diseases and immense opportunities of global action
to control them.
Global Burden of Cardiovascular Diseases
Burden in the Asia Pacific Region
Risk Factors Prevalence and Trends
Major Challenge for the 21st Century
CVD Burden of Disease and Investment: The Great Disconnect
Is There Hope?
Call to Action
Global Burden of Cardiovascular Disease:Challenges AheadGlobal Burden of Cardiovascular Disease:Challenges Ahead
Causes For the Rising Burden of CVDCardiovascular Risk Factors `
Causes For the Rising Burden of CVDCauses For the Rising Burden of CVDCardiovascular Risk FactorsCardiovascular Risk Factors `̀
World Health Organization, 2002
Non-modifiableRisk Factors
NonNon--modifiablemodifiableRisk FactorsRisk Factors
• TobaccoTobacco•• DietDiet•• AlcoholAlcohol•• Physical ActivityPhysical Activity
Socio-economic, cultural & environmental
factors
Socio-economic, cultural & environmental
factors
INTERMEDIATERISK
FACTORS
INTERMEDIATEINTERMEDIATERISKRISK
FACTORSFACTORS
• Hypertension• Diabetes• Obesity
• Coronaryheart disease
• Stroke
• Peripheralvascular disease
AgeAgeSexSex
GenesGenes
BEHAVIOURALRISK FACTORSBEHAVIOURALRISK FACTORS
ENDPOINTSENDPOINTSENDPOINTS
3 RISK FACTORS - TOBACCO USE, POOR DIET AND LACK OF PHYSICAL ACTIVITY
FOUR MAJOR CHRONIC DISEASE - HEART DISEASE, DIABETES, LUNG DISEASE AND CANCERS
50 PERCENT OF DEATHS IN THE WORLD
3FOUR5033FOURFOUR5050
Source : “Global Burden of Disease and Risk Factors”, Lopez and others, Oxford University Press, 2006
6 of top 10 risk factors in low- and middle- income countries lead to CVD
6 of top 10 risk factors in low- and middle- income countries lead to CVD
Risk factor for CVD
www.who.int/whr/2002
GLOBAL DISTRIBUTION OF BURDEN OF DISEASE ATTRIBUTABLE TO 14 LEADING SELECTED RISK FACTORS
GLOBAL DISTRIBUTION OF BURDEN OF DISEASE GLOBAL DISTRIBUTION OF BURDEN OF DISEASE ATTRIBUTABLE TO 14 LEADING SELECTED RISK FACTORSATTRIBUTABLE TO 14 LEADING SELECTED RISK FACTORS
Kearney et al. Lancet 2005;365:217-23.
Frequency of Hypertension in People Aged 20 Years and Older by World Region and Sex in
2000 (Upper) and 2025 (Lower)
Frequency of Hypertension in People Aged 20 Years Frequency of Hypertension in People Aged 20 Years and Older by World Region and Sex in and Older by World Region and Sex in
2000 (Upper) and 2025 (Lower)2000 (Upper) and 2025 (Lower)
37.4 35.3
20.6
40.7
22 22.617
26.9
37.2 39.1
20.9
34.8
23.719.7
14.5
28.3
0
10
20
30
40
50Men
Womwn
41.6 39.1
22.9
44.5
24 27.718.8
27
42.5 45.9
23.6
40.227 27
17.128.2
01020304050
Establishedmarket
economies
Formersocialist
economies
India Latin Americaand the
Caribean
Middleeastern
crescent
China Other Asiaand islands
Sub-SaharanAfrica
2000
2025
Rat
e of
hyp
erte
nsio
n (%
)
All smoking prevalence
05
1015202530354045
Low income Low er-middleincome
Upper-middle income High income
%
Q1 Q2 Q3 Q4 Q5
Range: from Q1 = poorest quintile to Q5 = Highest income quintile
Cardiovascular DiseasesThe poorest people in developing countries are the ones who smoke the most
Cardiovascular DiseasesThe poorest people in developing countries are the ones who smoke the most
Source: World Health Survey 2006
SOCIAL INEQUALITIES IN MALE MORTALITY IN FROMSMOKING AND FROM ANY CAUSE (1996)
SOCIAL INEQUALITIES IN MALE MORTALITY IN FROMSMOKING AND FROM ANY CAUSE (1996)
P Jha et al., Lancet 2006; 368:367
50
40
30
20
10
0
Englandand Wales
USA Canada Poland
Social class NeighborhoodIncome
EducationEducation
Ris
kof
dyi
ng a
t age
s 35
-69
year
s (%
)
High (I/II)
Med (II
I/IV)
Low (V)
Low (<12
yrs)
Med (1
2 yrs)
High (>12
yrs)
Low (<12
yrs)
Med (1
2 yrs)
High (>12
yrs)
High (20%
)Med
(60%
)Low (2
0%)
43%
31%
21% 20%
37%34%
36%
21%24%
26%
50%
32%
22%
10%
5%6% 8%
13%14% 15%
4%4%
10%
19%
SmokingAny Cause
Global Burden of Cardiovascular Diseases
Burden in the Asia Pacific Region
Risk Factors Prevalence and Trends
Major Challenge for the 21st Century
CVD Burden of Disease and Investment:
The Great Disconnect
Is There Hope?
Call to Action
Global Burden of Cardiovascular Disease:Challenges AheadGlobal Burden of Cardiovascular Disease:Challenges Ahead
Millennium Development GoalsMillennium Development Goals1. Eradicate poverty and hunger2. Achieve primary universal education3. Promote gender equality and empower
women4. Reduce child mortality5. Improve maternal health6. Combat HIV/AIDS, malaria and other
diseases7. Ensure environmental sustainability8. Develop a global partnership for
development
Cardiovascular diseasemust be included
Yet current investment in chronic NCDs
is very low…
Yet current investment in chronic NCDs
is very low…For the 2008-2009 biennum, the WHO will allocate almost US$ 900 million to communicable disease whereas the budget allocated to non-communicable disease barely reaches US$ 160 million
The Global Fund for HIV/AIDS, TB and Malaria total pledges paid to date: USD 11.8 billion
Half of the US$ 1.8 billion allocated to health programmes by USAID in 2003 were for HIV/AIDS and infectious diseases. Another 45% were for maternal health, child survival and population control.
Out of US$20.6 billion in Official Development Assistance in 2006 provided by 24 OECD/DAC countries and the EC, $ 0.1 billion went to basic nutrition and there was no specific investment in the prevention and control of NCDs.
Specific example of tobacco control: under-funded compared with other leading causes of deathSpecific example of tobacco control: under-funded compared with other leading causes of death
$0
$5
$10
$15
$20
AIDS TB Malaria Tobacco
Glo
bal F
undi
ng ($
Bill
ions
)
0
1
2
3
4
5
Ann
ual D
eath
s (m
illio
ns)
Global Funding, 2007 (allsources, $ billions)
Annual Deaths (millions)
World Health Organization
Comparison of total DALYs by region and total health expenditure by region
Comparison of total DALYs by region and total health expenditure by region
(CJ L Murray, Global burden of disease study. The Lancet, 1997
DALYs by region(% total DALYs worldwide, 1990)
DALYs by region(% total DALYs worldwide, 1990)
CHN
FSE
EME
SSA
IND
MEC
OAILAC
Health expenditure by region(% health expenditure worldwide, 990)
Health expenditure by region(% health expenditure worldwide, 990)
7.2%
CHN
FSE
EME
SSA
IND
MEC
OAI
LAC
87.3%
The 10/90 Gap in Health Financing
The 10/90 Gap in Health Financing
Cardiovascular Care in Pakistan: Treatments by SESCardiovascular Care in Pakistan: Treatments by SES
In Patients(2006)
In Patients(2006)
60 %
21 %
10 %
9 %
Out Patients (2006)
Out Patients (2006)
8 %8 %
7 %
77 %
Total PCI 1886
Total PCI 1886
64 %
7 %
13 %
16 %
■ Paying ■ Poor
■ G. User ■ Entitled
S. Sheikh, ESC, 2007
CREATE REGISTRY: Treatments by SESCREATE REGISTRY: Treatments by SES
Key Treatments RichUpper middle class
Lower middle class
Poor p value
N 5.3% 22.5% 52.5% 19.6%
<0.0001
0.12
<0.0001
<0.0001
ACE inhibitors or ARB 63.2% 57.1% 57.1% 54.1% <0.0001
Anticoagulants 89.4% 84.0% 82.2% 75.2% <0.0001
PCI 15.3% 13.0% 6.4% 2.0% <0.0001
CABG 7.5% 4.9% 2.4% 0.7% <0.0001
Thrombolysis† 60.6% 64.5% 98.0% 97.9%
Antiplatelet drug 97.0% 97.6% 98.0% 97.9%
Beta blockers 58.8% 61.2% 62.0% 49.6%
Lipid-lowering drugs 61.2% 58.7% 54.2% 36.2%
Xavier D et al Lancet 2008
Global Burden of Cardiovascular Diseases
Burden in the Asia Pacific Region
Risk Factors Prevalence and Trends
Major Challenge for the 21st Century
CVD Burden of Disease and Investment: The Great Disconnect
Is There Hope?
Call to Action
Global Burden of Cardiovascular Disease:Challenges AheadGlobal Burden of Cardiovascular Disease:Challenges Ahead
Age-adjusted Mortaligy rates of
Coronary heartDisease in North
Karelia and theWhole of Finland
among males aged35-64 years from
1969 to 1995.
Age-adjusted Mortaligy rates of
Coronary heartDisease in North
Karelia and theWhole of Finland
among males aged35-64 years from
1969 to 1995.0
200
400
600
800
69 71 73 75 77 79 81 83 85 87 89 91 93 95
Start of the North Karelia ProjectExtension of the Project Nationwide
North KareliaNorth Karelia
All FinlandAll Finland
Mortality per100 000
Population
-65%-65%
-73%-73%
Year
Knowledge: Prevention Works 1Knowledge: Prevention Works 1
VartiainenVartiainen E, P. E, P. PuskaPuska, BMJ , BMJ 309309; 1994 ; 1994
9%Treatment of AMI
Contribution of treatments and risk factor changes to the decline in CHD mortality in
Finland 1982-1997
Contribution of treatments and risk factor Contribution of treatments and risk factor changes to the decline in CHD mortality in changes to the decline in CHD mortality in
Finland 1982Finland 1982--19971997
8%Invasive treatment
2%Medical Treatment
of Angina
22%Not explained
2%Heart Failure Treatment
7%Blood Pressure
30%Cholesterol
9%Smoking
8%Secondary prevention
Exploring the fall in CHD deaths in USA in 1980-2000
Exploring the fall in CHD deaths in USA in 1980-2000
Risk Factors Worse +17%Risk Factors Worse +17%Obesity (Increase) +7%Diabetes (Increase) +10%
Risk Factors Better -65%Risk Factors Better -65%Population BP fall -20%Smoking -12% Cholesterol (diet) -24%Physical Activity -5%
Treatments -47%Treatments -47%AMI Treatments -10%Secondary Prevention -11% Heart Failure -9%Angina: CABG & PTCA -5%Hypertension Theropies -7%Statin (Primary Prevention) -5%
Unexplained -9%Unexplained -9%
342,000fewer deathsin 2000
342,000fewer deathsin 2000
19801980 20002000
NEJM 2007, 256, 2388
Global Burden of Cardiovascular Diseases
Burden in the Asia Pacific Region
Risk Factors Prevalence and Trends
Major Challenge for the 21st Century
CVD Burden of Disease and Investment: The Great Disconnect
Is There Hope?
Call to Action
Global Burden of Cardiovascular Disease:Challenges AheadGlobal Burden of Cardiovascular Disease:Challenges Ahead
Risk
of M
I
Risk
of M
I
77.5%77.5%
15%15%
7.5%7.5% > 20%> 20%
< 10%< 10%
“High Risk” vs “Population”“High Risk” vs “Population”
POPULATIONPOPULATION
10-20%10-20%
CVD PREVENTIONCVD PREVENTION
RISKRISK
TAKE
AIM
TOGETHER
TAKE TAKE
AIM AIM
TOGETHERTOGETHER
Chol
este
rol
Chol
este
rol
Toba
cco
Toba
cco
Hyp
erte
nsio
n
Hyp
erte
nsio
n
Obe
sity
Obe
sity
Phy
sica
l
Phy
sica
l
Inac
tivi
ty
Inac
tivi
ty
FAMILY &
COMMUNITY LEVEL
FAMILY &
COMMUNITY LEVEL
RISK FACTORSRISK FACTORS
POLITICAL WILL
PUBLIC AWARENESS
INTERNATIONAL SUPPORTMEDIA
SCIENTIFIC EVIDENCE
Working togetherfor
WAR ON HEART DISEASE
SummarySummaryGrand ChallengesGrand Challenges
« A crucial aspect of establishing programs for disease control globally is to identify priorities. To galvanize the health science and public policycommunities into action on this epidemic… »
Socioeconomic gradient remains the most important barrier amongst the countries, or within a developing country, for appropriate application of cardiovascular care.
Source : Nature, Vol. 450, 22 November 2007
Knowing is not enough; we must apply.Willing is not enough; we must do.
Johann Wolfgang von Goethe(1749–1832)
Knowing is not enough; we must apply.Knowing is not enough; we must apply.Willing is not enough; we must do.Willing is not enough; we must do.
Johann Wolfgang von Goethe(1749–1832)
UNITE FOR WAR ON HEART DISEASE